c 


LIBERTY  TEES   BLOCK, 

m:  a  y,     1  e  6  1 . 


H 


THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 


PRESENTED  BY 

PROF.  CHARLES  A.  KOFOID  AND 

MRS.  PRUDENCE  W.  KOFOID 


LETTERS 


A  YOUNG   PHYSICIAN 


JUST  ENTERING  UPON  PRACTICE. 


PROFESSOR    EMERITUS    OF    THE    THEORY    AND    PRACTICE  OP  PHYSIO  IN  THE  UNI 

VKR3ITY  AT  CAMBRIDGE  J    LATE  PHYSICIAN  IN  THE  MASSACHUSETTS  GENERAL 

HOSPITAL  ;     HONORARY    MEMBER     OF     THE     MEDICO-CHIRURGICAL 

SOCIETY     OF     LONDON  ;     CORRESPONDING    MEMBER    OF 

THE  ACADEMY    OF   MEDICINE   AT   PARIS, 

&c.  &c.  &0  ■ 


jrrnt)  mtsiuon. 


BOSTON: 
TICKNOR    AND    FIELDS.. 
1861. 


<ivvX 


Entered  according  to  Act  9f  Congress,  in  the  year  1856,  by 

JAMES   JACKSON, 

In  the  Clerk's  Office  of  the  District  Coiu-t  for  the  District  of  Massachusetts. 


Bt«teoc;ped  by 

HOBABT  «   R0BBIN8, 

r  England  Type  and  Stereotype  Fonndery 

B08T0X. 


CONTENTS. 


Pagb 

Dedication, 3 

Letter 

I.  —  Inteoductoet, 7 

H.  —  On  Conduct  in  the  Sick-room, 25 

in.  —  On  the  Neevous  System  and  on  Headache,     ...    42 

IV.  —  On  Epilepsy  and  the  Convulsion-fits  of  Young 

Children, 61 

V.  —  On  Apoplexy  and  Palsy, 74 

VI.  —  On  Choeea,  Neuealgia  and  Pain, 85 

Vn.  —  On  Somnambulism,  Animal  Magnetism  and  Insanity,  92 
Vm.  —  On  Dentition  and  the  Peeiod  of  Weaning,  .   .   .  107 

IX.  —  On  Choleea  Infantum,  the  Second  Dentition, 

AND  Ulcusoula  Oeis, 129 

X.  —  On  Abscess  in  the  Tonsils,  Elongated  Uvula, 

Beonchitis   and   Pneumonitis,   Rheumatism, 

AND  Gout, 154 

^I.  —  On  Phthisis  and  HiEMOPTYSis,  ..........  173 

XIL— On  Dyspepsy, 208 


IV  CONTENTS. 

Xni.  —  On  Some  Diseases  op  the  Intestines,  particu- 
larly  OF  THE   CCECUM  AND   COLON, 232 

XIV.  —  On  Constipation  of  the  Bowels,     .......  271 

XV.  —  On    Bilious    Diseases,    Biliary    and    Urinary 

Calculi,  and  Irritable  Bladder, 297 

XVI.  —  On  Boils, 306 

XVII  —  On  the  Treatment  of  Typhoid  Fever, 326 


to 


JOHN    C.    WARREN,    M.  D., 

PROFESSOR    EMERITUS    OF    ANATOMY   IN    THE    UNIVERSITY   AT    CAJt 
BRIDGE  ;     LATE    SURGEON    IN     THE     MASSACHUSETTS     GENERAL 
hospital;    I'RESIDENT   OF  THE  BOSTON   SOCIETY    OF    NATU- 
RAL   history;    HONORARY   MEMBER   OP    THE    MEDICO- 
CHIRURGICAL     SOCIETY      OF      LONDON  ;     CORRE- 
SPONDING   MEMBER     OF     THE   ACADEMY     OF 

medicine  at  paris,  etc.,  etc.,  etc. 

My  dear  Friend, — 

I  have  been  writing  some  letters  to  a  young  physician, 
and  am  about  to  publish  them,  I  beg  leave  to  introduce 
them  to  the  public  by  a  letter  of  dedication  to  you.  To 
whom  can  I  so  properly  dedicate  them  as  to  my  oldest 
medical  friend,  one  with  whom  I  have  lived  in  close  inti- 
macy for  more  than  half  a  century  ?  Is  it  not  a  great 
satisfaction  to  look  back  to  the  many  objects  we  have 
pursued,  and  labors  we  have  performed,  together,  during 
this  period  ? 

It  is  not  my  intention  to  eulogize  you,  or  to  attempt  to 
extend  a  reputation  which  has  long  since  spread  further 
than  my  voice  can  reach.  We  have  tried  an  experiment, 
and  I  am  inclined  to  state  to  the  young  men  of  our  pro- 
fession what  it  was,  and  what  have  been  its  results. 
There  will  be  a  little  boasting  in  it ;  but  the  young  must 
indulge  their  seniors  in  boasting;  when  they  are  getting 
past  service,  it  may  be  all  that  is  left  for  them.  Allow 
I 


Z  PREFATORY   AND    DEDICATORY. 

me,  then,  in  this  public  letter  to  give  an  account  of  our 
experiment. 

You  and  I  began  our  active  lives  in  this  city  nearly  at 
the  same  time.  It  was  when  Boston  had  about  one  sixth 
of  its  present  population,  and  I  suppose  much  less  than  a 
sixth  of  its  present  wealth.  We  were  so  circumstanced 
as  to  be  peculiarly  rivals.  Our  business  led  us  across 
each  other's  paths  every  day  for  a  long  series  of  years. 
What  one  gained,  the  other  seemed  to  lose.  It  would 
have  been  very  easy  for  us  to  have  got  up  a  pretty  quar- 
rel at  any  moment ;  and  having  once  begun,  we  might  each 
have  got  partisans,  and  all  the  usual  entanglements  to 
such  cases  appertaining  might  have  followed.  Happily, 
we  pursued  a  diflferent  course.  We  met  together  with  the 
feelings  we  had  had  as  fellow-students.  We  took  much 
delight  in  consultation  and  discussion  on  professional  sub- 
jects, and  were  ever  ready  to  help  each  other.  We  have, 
indeed,  maintained  a  strong  personal  interest  in  each 
other's  welfare,  and  promoted  each  other's  happiness. 
We  do  not  resemble  each  other  in  temperament,  and  can- 
not see  all  things  alike.  From  this  cause,  and  not  always 
looking  at  objects  from  the  same  point  of  view,  we  often 
diflfered  in  opinion.  But  we  have  always  agreed  to  dijffer. 
We  have  not  often  disputed,  and  never  have  quarrelled 
on  account  of  this  difference  of  opinion,  nor  on  any  other 
account.  In  our  intercourse  with  the  sick,  each  has  given 
the  other  credit  for  what  was  good  in  him,  instead  of 
studying  and  publishing  the  other's  faults.  In  every 
work  for  the  promotion  of  medical  science,  or  for  elevating 
the  profession,  we  have  cooperated  heartily,  neither  of  us 
trying  to  push  the  other  aside.  And  thus  it  is,  that  being 
now,  as  regards  age,  in  the  front  rank  in  our  profession, 


PREFATORY  AND  DEDICATORY.         3 

we  have  continued  to  this  day  on  terms  of  intimacy  and 
friendship.  This  is  something  to  rejoice  in,  and  something 
for  which  we  may  properly  thank  God ;  and  I  know  you 
will  join  me  in  giving  thanks  reverently. 

As  we  are  near  the  end  of  our  journey,  I  hope  I  may 
be  excused  for  stating  this  experiment  and  its  results.  I 
would  show  to  young  men  how  grateful  these  results  are. 
I  can  say  to  them  that  our  interests  have  been  promoted 
by  our  friendly  treatment  of  each  other ;  that  each  of  us 
has  gained  by  it  much  more  than  either  of  us  could  have 
done  by  the  sharpest  quarrels.  If  they  believe  me,  any 
two  of  them,  placed  side  by  side,  as  we  were,  may  be 
induced  to  try  the  plan  of  a  peaceful  competition. 

Enough,  as  regards  ourselves.  As  regards  the  breth- 
ren, who  have  multiplied  about  us  since  we  began  our 
course,  we  have  much  cause  for  rejoicing.  We  were 
pioneers  in  a  country  not  new,  but  not  much  cleared.  We 
were  not  fully  aware  of  it  then,  but  when  we  commenced 
our  career,  our  country  had  just  begun  to  be  assured  of 
prosperity  after  the  hard  and  exhausting  revolution  it 
had  undergone.  I  will  not  indulge  myself  in  relating  to 
the  young  all  the  changes  which  have  taken  place  since  I 
began  business  in  1800.  I  will  not  point  out  how  much, 
necessary  to  elevate  the  profession,  was  yet  to  be  done.  I 
cannot  be  supposed  to  intimate  any  deficiency  in  our 
predecessors.  The  community  was  not  rich  enough  to 
encourage  or  aid  in  works  for  the  public  welfare.  But 
the  time  was  coming.  We  happened  to  be  so  situated  as 
to  be  called  to  work.  Jumores  ad  lahores  was,  not  in 
words,  but  in  effect,  the  motto,  under  which  we  were 
brought  into  service ;  and  our  arms,  such  as  they  were, 
with  implements  quite  inferior  to   such   as   the   present 


i  PKEFATORY   AND    DEDICATORY. 

day  can  furnish,  were  occupied  in  felling  the  trees.  We 
worked  to  get  up  some  log  houses,  useful  for  a  time,  but 
which  we  pulled  down  when  no  longer  wanted.  We  have 
since  then  aided  in  getting  up  edifices  more  costly,  and 
"destined,  I  trust,  to  be  permanently  useful. 

It  has  been  my  delight  for  many  years  past,  as  I  be- 
lieve it  has  been  yours,  to  point  out  to  others  what  a 
respectable  body  of  junior  practitioners  has  been  rising 
up  around  us.  Compare  the  power  of  distinguishing  dis- 
eases, and  the  discretion  in  treating  them,  shown  in  young 
men  of  the  present  day,  with  the  like  characteristics  of 
our  medical  men  forty  years  ago,  and  you  will  find  the 
advance  to  be  very  honorable.  Medical  science  has  been 
increasing  in  Europe  and  in  this  country.  Our  younger 
men  have  had  great  masters.  Not  to  mention  our  own 
countrymen,  they  have  had  Laennec  and  Louis,  and  many 
©thers  among  the  French ;  in  Great  Britain  and  Ireland 
too  many  to  be  named ;  and  a  host  of  surgeons,  of  whom 
you  could  best  give  the  list.  It  may  be  said  that  it 
would  have  been  shameful  if  they  had  not  acquired  much. 
But  no  such  reproach  falls  on  them ;  on  the  contrary,  it  is 
due  to  them  to  say,  that  they  have  ftilly  availed  them- 
selves of  their  opportunities.  For  my  own  part,  in  look- 
ing at  one,  and  now  another,  who  have  succeeded  me  in 
office,  I  think  it  enough  to  boast  of  that  I  aided  in  teach- 
ing them  how  to  learn.  I  should  be  sorry  to  believe  that 
they  had  not  gone  ahead  of  their  predecessor.  I  only 
beg  that  thSy  will  allow  him  to  be  a  sort  of  honorary 
member  in  the  corps  of  i/outk/  physic. 

Let  me  put  an  end  to  this  rambling,  lest  some  oner 
smile  at  the  garrulity  of  old  age.  I  designed  this  letter 
not  only  as  a  dedication^  with  reminiscences  attached  to 


PREFATORY   AND    DEDICATORY.  5 

it,  but  also  as  an  introduction,  or  preface,  to  the  letters 
which  are  to  follow  it.  You  might  guess  that  I  was 
stirred  up  to  write  a  book  by  the  success  with  which  my 
fellow  ex-professors  had  been  doing  the  like.  If  I  could 
succeed  as  well  as  the  rest  of  you,  it  would  be  inducement 
enough.  But,  in  truth,  the  project  has  been  in  my  mind 
a  long  while.  The  physical  objections  to  much  confine- 
ment in  my  study  have  kept  me  back.  But  early  in  this 
year  I  decided  to  undertake  the  task,  and  from  that  time 
have  given  to  it  all  the  labor  I  was  capable  of.  In  this 
undertaking  I  flattered  myself  I  could  be  of  some  service 
to  young  physicians  just  coming  into  practice.  I  did  not 
propose  a  systematic  work;  but  I  thought  it  possible, 
availing  myself  of  the  form  and  license  of  letters,  to  give 
whatever  useful  thing  my  experience  could  furnish.  Had 
I  kept  notes  of  cases  in  private  practice,  I  might  have 
been  able  to  give  information  in  a  more  precise  form 
But  this  I  have  »not  done,  finding  that  it  drew  ofi"  my 
attention  too  much  from  the  case  itself.  I  have,  however, 
always  endeavored  to  keep  the  results  of  experience  in 
my  mind,  so  as  to  have  them  ready  for  use  at  the  bed- 
side. Now  I  have  run  my  eyes  over  the  list  of  diseases 
strictly  medical,  and  whenever  I  have  recalled  anything 
worthy  to  be  brought  forward,  I  have  stated  it,  more  or 
less  fully,  as  the  case  seemed  to  require.  I  have  not 
given  cases  in  support  of  my  statements.  When  I  have 
furnished  cases,  it  has,  generally,  been  by  way  of  illus- 
tration, not  as  proofs.  I  have  described  diseases,  so  far 
as  necessary  for  my  purpose,  but  without  attempting  to 
give  full  delineations  of  them.  I  should  except  from 
this  remark  some  morbid  affections,  which  I  think  have 
1* 


6  PREFATORY   AND    DEDIGATORT. 

been   imperfectly  understood,  or  not  at  all  described  by 
others.     An  instance  of  this  jou  will  find  in  Letter  XIII. 

It  may  be  said  that  I  have  gone  into  theoretical  ques- 
tions, and  certainly  into  the  discussion  of  first  principles, 
such  as  do  not  belong  to  a  plain,  practical  work.  There 
is  an  instance  of  this  in  the  letter  on  nervous  diseases. 
My  reply  is,  that,  for  practical  purposes,  I  think  a  disease 
should  be  first  viewed  in  its  simplest  form  and  in  the 
clearest  light ;  free  from  extraneous  circumstances.  This 
is  what  I  have  attempted  to  bring  about  in  the  discussion 
above  referred  to,  and  on  some  other  occasions. 

Let  me  hope  that  the  work  may  be  worthy  of  youi 
approbation,  and  that  it  may  be  useful  to  the  class  of  per- 
sons for  whom  it  is  designed. 

With  the  best  wishes  for  your  health  and  happiness, 
I  remain,  as  always, 

sincerely  your  friend, 

JAMES  JACKSON 

Hamiliox  Place,  August,  185S. 


LETTER    I. 

INTRODUCTORY. 

I  CONGRATULATE  you,  my  joung  friendj  on  having 
arrived  at  the  period  on  which  your  eyes  have  long 
been  fixed:  the  period  at  which  your  education  is 
terminated,  and  at  which  you  are  to  enter  upon  the 
serious  business  of  your  profession.  Your  education, 
I  say,  is  terminated.  You  are  told,  indeed,  that  you 
must  continue  to  educate  yourself  through  life.  With- 
out quarrelling  about  words,  I  think  this  does  not 
present  the  subject  in  its  true  point  of  view.  I  agree 
that  you  are  bound  to  study  and  to  increase  your 
knowledge  as  long  as  you  continue  to  be  engaged  in 
your  profession.  But  you  are  now  educated;  you 
are  brought  out.  You  are  now  placed  on  the  course 
where  you  are  to  run  your  race.  You  look  at  the 
objects  before  you  from  a  new  point.  You  have  put 
on  your  working-dress,  and  you  are  to  go  to  business. 


8  INTRODUCTORY. 

From  this  day  jou.  must  realize,  more  and  more,  the 
diiFerence  between  the  study  of  the  sciences  and  the 
application  of  them  to  the  business  of  life, —  to  the 
practice  of  your  art.  You  may,  before  this,  have 
tried  your  hand  at  practice;  but  it  has  been  as  an 
apprentice,  and  not  with  the  feelings  of  responsibility 
belonojinor  to  the  master- workman. 

In  some  respects  I  should  call  on  you  for  instruc- 
tion, rather  than  offer  instruction  to  you.  For 
instance,  knowing  how  you  have  applied  yourself,  I 
should  regard  you  as  an  authority  in  microscopic 
anatomy,  or  on  nice  points  of  organic  chemistry. 
But  I  have  been  working,  in  my  fashion,  for  more 
than  half  a  century.  I  have  been  travelling  through 
the  country  upon  which  you  are  entering.  Its  high- 
roads and  its  by-paths  are  somewhat  familiar  to  me. 
You  have  studied  them  in  the  books  and  on  the 
maps,  and  I  doubt  not  you  have  studied  them  well. 
Yet  I  may  be  able  to  communicate  to  you  some  useful 
knowledge  respecting  them,  although  it  relates  to  small 
matters  only.  However,  that  I  may  not  seem  to  dis- 
parage myself,  I  will  acknowledge  a  hope  that  there 
may  be  some  few  points  of  real  importance  on  which  I 
can  enlighten  you. 

It  is  my  object  in  these  letters  to  point  out  to  you 
m  a  familiar  manner  whatever  occurs  to  me  as  likely 


INTEODUCTORY.  9 

to  aid  you,  and  which  the  books  do  not  say  much 
about.  I  shall  not  be  perfectly  methodical,  yet  I 
shall  endeavor  to  hold  to  some  plan.  This  may  be 
regarded  as  an  introductory  letter,  in  which  I  may 
treat  of  matters  and  things  in  general. 

Ours  is  said  to  be  a  liberal  profession.  This  is  often 
said,  with  some  vague  notions  of  its  dignity,  by  those 
who  are  not  aware  why  it  has  been  called  so.  It  has 
been  customary,  you  know,  for  those,  who  designed  to 
acquire  a  knowledge  of  any  mechanic  art,  to  be  bound 
as  apprentices  to  some  master-workman.  .  Now,  an 
apprentice  is  a  servant,  though  he  may  not  be  a  menial 
servant.  He  works  for  his  master's  benefit,  and  at 
his  master's  bidding.  It  was  the  case  formerly,  and 
I  believe  it  is  so  at  the  present  day,  in  our  father- 
land, and  in  Europe  generally,  that  common  surgeons 
and  apothecaries  learned  their  arts  in  the  same  way. 
But  it  was  never  so  as  to  physicians.  They  did  not 
pursue  their  studies  under  bonds,  but  like  clergymen 
and  lawyers,  as  freemen.  Hence  the  professions  of 
these  three  descriptions  of  men  have  been  called  lib- 
eral. At  present,  you  know,  physicians  and  surgeons 
take  the  same  rank,  or  nearly  so,  in  England,  and 
altogether  so  in  this  country.  Indeed,  with  very 
rare  exceptions,  the  two  professions  are  not  distinct 


10  INTRODUCTORY. 

I  have  been  led  into  these  remarks  because  I  think 
that  some  members  of  our  profession  have  called  it 
liberal,  with  false  notions  on  the  subject.  Thej  have 
thought  not  onlj  that  thej  differed  from  artisans,  but 
they  have  seemed  almost  to  believe  that  they  were  not 
practising  an  art.  They  have  seemed  to  regard  them- 
selves as  professors  of  a  science,  by  which  they  could 
explain  all  the  causes  of  diseases,  and  the  true  modes 
of  treating  them.  I  rejoice  to  say  that,  in  some 
instances,  this  is  true;  and  it  is  among  the  most 
delightful'  parts  of  our  business  when  we  can  instruct 
an  enlightened  man  in  the  principles  w^hich  should 
guide  him  in  the  attainment  of  health.  It  is  not 
often,  however,  that  we  can  have  this  pleasure,  for  two 
reasons  :  First,  because  many  principles,  on  which  we 
act,  are  not  established  on  certain  ground ;  and  there- 
fore they  must  be  followed  with  great  caution  and 
constant  watchfulness.  Second,  because  there  are 
few  principles  which  are  universal  in  their  applica- 
tion. In  its  application  every  principle  is  subject  to 
the  limitation  of  other-  principles.  We  are  not,  then, 
acting  on  so  grand  a  scale,  always  guided  by  well- 
settled  principles  of  science ;  we  are  often  glad  of  the 
most  limited  empirical  knowledge,  and  often  obliged 
to  choose  our  course  under  much  doubt.  These  diffi- 
culties are  great  j  but  they  are  not  greater  than  those 


INTRODUCTORY.  11 

attending  the  application  of  principles  to  practice  m 
many  common  affairs  of  life,  where  the  circumstances 
are  complicated.  There  is  a  marked  resemblance,  in 
certain  fundamental  points,  between  our  art  and  the 
arts  of  agriculture  and  navigation.  In  the  practice  of 
each  of  these  arts  we  avail  ourselves  of  the  laws  of 
nature  to  produce  certain  results.  The  seaman  places 
his  machine  —  his  ship  —  upon  the  waters,  and  avails 
himself  of  the  winds  to  propel  it.  These  winds  are 
uncertain ;  thej  are  not,  in  any  way,  subject  to  his 
control,  so  that  he  cannot  be  sure  as  to  the  duration, 
the  comfort,  nor  even  the  safety  of  his  voyage.  He 
cannot  furnish  a  pupil  with  positive  rules,  by  which 
to  conduct  his  bark  across  the  Atlantic.  The  captain 
must  have  first  a  knowledge  of  the  principles  of  navi- 
gation ;  but  this  is  not  enough.  In  applying  them  he 
must  have  regard  to  the  qualities  of  his  ship,  to  the 
strength  of  his  crew,  and  to  the  constantly  varying 
circumstances  of  the  weather.  The  complexity  here 
is  much  less  than  that  attending  the  treatment  of  a 
disease ;  for  in  this  we  have  to  do  with  a  living  being. 
It  is  not  strange,  then,  that  the  physician  cannot 
always  foretell  the  length  or  the  amount  of  suffering 
of  a  disease,  or  the  ultimate  issue  of  it.  All  this  is 
consistent  with  the  wisest  management  on  the  part  of 
the  navigator,  or  that  of  the  physician.     It  is  much 


12  INTRODUCTORY. 

the  same  with  the  agriculturist.  He  may  prepare  his 
ground  with  the  most  appropriate  manures,  and  give 
to  it  the  nicest  tilth;  he  may  sow  his  seed  at  the 
proper  season  ;  and  yet  his  expectations  as  to  the  har- 
vest may  be  entirely  disappointed.  Not  only  may  the 
weather  be  unpropitious,  but,  at  the  moment  when  the 
skies  and  the  winds  are  favorable,  and  when  success 
seems  certain,  some  insect  army  may  suddenly  invade 
his  fields  and  destroy  his  crop.  Thus  there  is  an 
uncertainty  in  dealing  with  the  powers  of  nature 
which  are  most  constant ;  for  there  is  a  good  degree 
of  constancy  in  the  results  of  agriculture  —  so  much 
that  we  are  rarely  disappointed  in  relying  on  it  for 
the  sustenance  of  man  and  beast.  Yet,  from  year  to 
year,  there  is  a  variation  in  its  results ;  and,  some- 
times, the  crops  fail,  in  particular  regions,  almost 
entirely.  Is  it,  then,  surprising  that  there  is  much 
uncertainty  in  the  success  of  the  medical  art ;  an  art 
which  has  to  do  with  a  diseased  body,  and  whose  end 
is  to  bring  back  this  body  to  the  healthy  functions 
which  belong  to  it  ?  More  especially,  can  this  uncer- 
tainty be  surprising,  when  this  diseased  body  has  been 
previously  damaged,  or  enfeebled  by  a  long  course  of 
errors  or  misfortunes  ?  While,  then,  we  acknowledge 
the  imperfection  of  our  art,  we  must  deny  that  this 
is  a  proper  subject  of  reproach.     It  is  so,  indeed,  as 


INTRODUCTORY.  13 

applied  to  those  who  profess  to  have  a  system,  by 
which  thej  can  explain  everything  and  effect  every- 
thing you  may  desire.  But  it  certainly  is  not  so 
when  applied  to  those  who  pursue  an  expectant,  or  an 
active  treatment,  as  circumstances  may  make  proper ; 
and  who  exercise  modesty  and  discretion,  as  well  as 
decision,  in  the  practice  of  their  art. 

I  am  very  desirous  to  place  this  matter  in  what 
appears  to  me  its  proper  light.  Those,  who  are  dis- 
posed to  think  ill  of  our  profession,  may  ask  how  we 
justify  the  use  of  powerful  and  dangerous  drugs,  while 
we  acknowledge  the  uncertainty  of  their  effects.  The 
evils,  they  say,  are  certain ;  the  benefits,  uncertain. 
This  is  true ;  and  the  question  implies  a  grave  objec- 
tion to  the  careless  use  of  such  drugs.  The  objection, 
however,  is  to  the  abuse  of  them.  They  should  not 
be  used  without  grave  consideration.  But  the  physi- 
cian, who  knows  all  the  risks  attending  the  use  of 
powerful  remedies,  may  also  know  within  what  limits 
they  are  safe ;  and  likewise  may  know  that  the  danger 
attending  his  patient's  case  is  much  greater,  than  that 
of  the  remedy.  Now,  I  contend  that  this  is  true  in 
regard  to  men  well  educated,  instructed  in  good  prin- 
ciples, and  endowed  with  sound  discretion. 

It  is  my  own  practice  to  avoid  drugs  as  much  as 
possible;  and  I  more  frequently  find  it  difficult  to 
2 


14  INTRO  DTJCTORY. 

persuade  people  to  abstain  from  using  them,  than  lo 
induce  them  to  take  them.  But  I  hope  that  jou  will 
not  believe  me  to  be  distrustful  of  the  power  of  drugs 
to  do  real  service  to  the  sick,  under  proper  circum- 
stances. I  am  far  otherwise.  And,  in  reference  to 
this  point,  I  wish  to  tell  you  that  your  success  in  the 
use  of  medicines  may  depend  somewhat  on  the  temper 
with  which  you  give  them.  You  must  be  hopeful  and 
feel  an  interest  in  them.  Do  not,  like  a  cold  step- 
father, leave  them  to  make  their  own  way  in  the  world ; 
but  watch  them  in  their  course.  You  cannot  make  a 
fire  burn  well  if  you  put  the  wood  on  the  andirons 
with  a  feeling  of  indiflference.  You  must  study  to 
know  the  power  of  the  drug  you  prescribe,  the  proper 
doscj  and  the  tests  of  a  sufficient  dose,  the  mode  of 
preparation  of  the  medicine,  and  then  of  the  patient 
for  the  medicine,  and  all  the  management  requisite  for 
a  good  result.  Do  not  be  in  a  hurry  to  give  credit  to 
your  prescription,  as  soon  as  the  patient  shows  any  sign 
of  amendment,  nor  be  discouraged  if  relief  do  not  fol- 
low as  soon  as  you  had  anticipated.  In  this  last  case 
see  if  there  has  not  been  some  error  in  the  manage- 
ment  of  the  affair,  or  if  some  counteracting  cause  has 
not  interfered.  Do  not  despair  because  the  medicine 
has  failed  on  your  first  trial  of  it.  Try  it  again, 
before  you  condemn  what  has  been  recommended  as 


INTRODUCTORY.  15 

beneficial  hj  one  well  qualified  to  form  a  judgment  on 
it.     I  have  wandered  from  mj  point. 

It  is  a  very  narrow  and  unjust  view  of  the  practice 
of  medicine,  to  suppose  it  to  consist  altogether  in  the 
use  of  powerful  drugs,  or  of  drugs  of  any  kind.  Far 
from  it.  ,  It  is  true  that  the  common  question  addressed 
to  the  physician  by  the  patient  is.  What  shall  I  take  ? 
That  question  implies  that  there  is  a  drug  adapted  to 
every  disease.  But  the  enlightened  physician  first 
considers  whether  the  patient  shall  take  anything. 
He  considers  what  other  modes  of  relief  there  are 
besides  pills  and  draughts.  He  looks  to  diet  and 
regimen.  To  these  points  I  shall  have  frequent  occa- 
sion to  refer. 

Let  it  be  remembered, —  and  we  may  address  this 
particularly  to  the  scofier, —  that  the  true  physician 
takes  care  of  his  patient  without  claiming  to  control 
the  disease  in  all  cases.  He  does  not  regard  himself 
as  making  an  exhibition  before  a  company  to  show  his 
skill ;  he  makes  no  boast  of  what  he  can  do.  I  wish 
I  could  say  that  this  is  never  done  by  any  of  our  pro- 
fession. There  are  those  who,  directly  or  indirectly, 
trumpet  forth  their  skill  and  their  success,  attributing 
the  recovery  of  their  patients  to  the  remedies  they 
have  prescribed,  and  never  to  the  spontaneous  efibrts 
of  nature.     These,  whatever  titles  may  be  appended 


16  INTRODUCTOBY. 

to  their  names,  are  true  quacks.  They  quack  !  quack  / 
that  they  may  attract  the  attention  of  the  passers-by ; 
and,  while  they  extol  their  remedies  for  the  sick- and 
the  suffering,  they  are  seeking  only  their  own  profit 
and  their  own  glory.  The  true  physician,  on  the 
other  hand,  cannot  fail  to  be  modest  in  his  pretensions ; 
for  he  is  aware  how  his  knowledge  and  power  are 
limited,  while  he  feels  the  magnitude  of  his  task.  Is 
it  his  business  to  cure  all  his  patients  ?  It  is  so,  if 
he  can  do  it,  even  in  the  sense  now  attached  to  the 
word  cure.  But,  in  the  original  sense  of  it,  he  should 
cure  all ;  for  in  that  sense  to  cure  meant  to  take  care. 
The  priest  had  the  parish  for  his  cure,  the  physician 
the  sick  for  his.  In  this  sense  the  sick  were  under 
his  cure  till  they  got  well  or  died,  if  they  were  willing 
to  remain  so.  The  physician  may  do  very  much  for 
the  welfare  of  the  sick,  more  than  others  can  do, 
although  he  does  not,  even  in  the  major  part  of  cases, 
undertake  to  control  and  overcome  the  disease  by  art. 
It  was  with  these  views  that  I  never  reported  any 
patients  cured  at  our  hospital.  Those  who  recovered 
their  health  before  they  left  the  house  Avere  reported 
as  toell^  not  implying  that  they  were  made  so  by  the 
active  treatment  they  had  received  there.  But  it  was 
to  be  understood  that  all  patients  received  in  that 
house  were  to  be  cured,  that  is,  taken  care  of. 


INTRODUCTORY.  17 

I  have  sometimes  had  patients  say  I  was  not  doing 
anything  for  them,  because  I  had  not  ordered  any 
medicine  to  be  taken.  It  may  be  that  the  patient  in 
Euch  a  case  thinks  that  no  medicine  will  remove  the 
disease,  and  is  right  in  his  opinion ;  yet,  something  is 
to  be  done,  but  not  by  medicine.  By  diet  and  regimen 
much  may  be  done  to  mitigate  suffering  and  prolong 
life.  In  all  cases,  in  the  worst,  there  is  one  course 
more  prudent  than  another.  If  the  ship  is  running 
on  to  the  shore,  or  is  even  breaking  up  on  the  rocks, 
there  may  be  one  course  better  than  another  in  the 
management  of  affairs.  In  the  worst  peril,  when  you 
must  leave  the  bark  to  which  you  had  trusted  yourself, 
in  whose  guidance  would  you  place  most  confidence  ? 
Would  you  leave  yourself  to  the  mercy  of  the  waves  ? 
Would  you  trust  an  ordinary  sailor  because  he  bawled 
the  loudest  ?  Or  would  you  follow  the  advice  of  the 
experienced  ship-master  ? 

Ours,  I  said,  is  a  liberal  profession.  While  studying 
tlie  sciences,  which  qualify  you  to  practise  the  art  of 
medicine,  while  deciding  what  rules  of  art  you  will 
adopt,  you  have  not  been  bound  to  follow  any  man  as 
a  guide ;  you  have  not  promised  fealty  to  any  intellect- 
ual master.  If  you  have  been  as  wise  as  I  think  you 
have,  you  have  weighed  the  characters  of  your  teach- 
ers, dead  and  living,  and  judged  for  yourself,  in  regard 
2^ 


18  INTRODUCTORY. 

to  each  of  them,  how  far  you  might  rely  on  him  for 
accuracy  and  honesty  in  stating  facts  and  observations, 
and  for  philosophical  accuracy  in  the  inferences  to  be 
drawn  from  them.  You  are  bound  as  by  an  oath, 
though  you  have  never  held  up  your  hand  before  man, 
to  use  your  best  judgment  in  the  treatment  of  those 
who  are  committed  to  your  care.  You  are  bound  to 
consult  the  best  teachers,  but  not  to  follow  the  orders 
of  any  individual  among  them. 

Ours  is  a  liberal  profession,  and  you  may  rejoice  in 
being  received  into  it.  There  are  to  be  found  in  our 
ancestry  father^  of  whom  we  may  be  proud.  First, 
Hippocrates,  whose  title  to  father  was  not  only  be- 
cause he  was  the  first  in  time  who  left  any  writings 
worthy  to  be  preserved,  but  also  because  he  pursued 
his  inquiries  in  the  truest  spirit,  and  in  the  best  mode. 
Like  all  scientific  writers,  he  employed  the  language 
of  the  day,  and  that  involved  the  received  doctrines 
and  hypotheses  of  the  day.  But  he  was  a  true 
observer  of  diseases  ;  he  noted  the  circumstances  under 
which  they  arose,  and  he  stated  the  treatment  he 
employed.  This  was  a  communication  of  knowledge. 
If  error  was  mixed  with  it,  the  wonder  is  that  so  much 
of  it  was  true  and  substantial  knowledge.  I  will  not 
give  you  a  list  of  the  worthy  successors  of  Hippoc- 
rates.    It  would  be  a  long  list,  though  I  should  select 


INTRODUCTORY.  19 

those  only  whose  claims  would  not  be  disputed.  I 
might  find  some  such  in  our  own  land,  who  ha^^e 
finished  their  career  in  the  present  century.  I  will 
indulge  myself  in  naming  one  only ;  one  w^hom  I  had 
the  happiness  to  know  intimately.  He  was  my  first 
teacher,  and  I  have  been  accustomed,  with,  some  others 
of  his  pupils,  to  call  him  old  master.  I  refer  to  the 
late  Edward  Augustus  Holyoke,  M.  D.,  of  Salem. 
He,  like  Hippocrates,  lived  more  than  a  hundred 
years,  retaining  his  faculties,  mental  and  bodily,  to 
the  end  of  his  century,  in  unusual  perfection.  But  it 
IS  not  for  his  longevity  that  I  mention  him  as  entitled 
to  a  high  rank  in  the  profession.  He  was  little  more 
than  fifty  years  of  age  when  our  Massachusetts  Medi- 
cal Society  received  its  charter,  and  in  that  Dr. 
Holyoke' s  name  stands  first  on  the  list  of  those  incor- 
porated. Upon  the  organization  of  the  society  he  was 
elected  its  first  president.  Thus  it  appears  that  his 
high  claims  were  acknowledged  by  his  brethren  at 
a  time  when  there  must  have  been  very  many  in  the 
state  older  than  he  was.  It  was  on  account  of  his 
professional  merit  that  he  was  thus  honored ;  but  all 
the  more  that  his  whole  character  was  most  worthy 
of  respect.  He  had  the  delicacy  of  taste,  as  shown  in 
his  manners  and  general  bearing,  which  grows  out  of 
a  fine  organization  and  of  a  cultivated  mind.     This 


20  INTRODUCTORY. 

was  accompanied  hj  true  piety ;  that  piety,  which  not 
only  elevates  the  heart  and  promotes  all  holy  affec- 
tions, but  also  clears  the  atmosphere  in  which  the  in- 
tellect dwells;  for,  it  is  certainly  true  that,  when 
all  the  lower  appetites  and  passions  are  kept  under 
control,  and  divine  things  are  made  real  to  the  mind, 
then  truth  will  be  discerned  most  clearly.  This  is 
peculiarly  obvious  as  regards  moral  subjects,  but  it  is 
not  limited  to  them. 

Dr.  Holyoke  ranked  among  our  first  men  in  his 
general  scientific  attainments.  But  the  great  object 
of  his  life,  industriously  and  faithfully  pursued,  was 
the  practice  of  medicine  in  its  various  branches.  He 
observed,  closely  and  critically,  the  phenomena  of 
disease  and  the  methods  of  treating  it.  His  concep- 
tions were  clear,  and  his  memory  strong ;  though,  like 
other  old  men,  he  lamented  its  decay,  in  the  latter 
part  of  his  life.  He  had  not  lost  it,  however,  as  was 
shown  on  the  day  which  completed  his  hundred  years, 
and  when  he  began  on  a  new  century.  On  that  day 
a  case  was  presented  to  him  of  an  unusual  character, 
on  which,  after  examining  it,  he  remarked  that  he  did 
not  recall  any  like  it,  unless  that  of  a  patient  whom 
he  named.  This  patient  was  one  whom  he  had  seen^ 
once  only,  forty  years  before.  He  had,  then,  a  great 
store-house  of  cases  in  his  mind ;  and  of  the  materials 


INTRODUCTORY.  21 

in  this  store-house  he  constantly  availed  himself.  He 
told  me  that  his  habit  was,  in  a  difficult  case,  first  to 
look  to  experience  for  a  guide ;  and  only  when  this 
was  deficient,  to  allow  himself  to  act  on  hypothetical 
principles.  After  considering  a  case,  he  would  decide 
upon  the  treatment  which  he  thought  best  adapted, 
and  would  pursue  this  with  firmness ;  watching,  how- 
ever, for  whatever  would  correct  his  opinions.  He 
was  too  modest  to  believe  that  he  had  become  a  perfect 
master  of  his  art,  and  too  wise  to  adventure  rashly 
where  human  life  was  at  risk.  He  had  great  dignity 
of  character,  such  that  it  seemed  to  prevent  the  exhi- 
bition of  any  bad  passions  in  his  presence  ;  but  it  was 
combined  with  the  greatest  modesty.  This  will  be 
understood,  when  I  add  that  this  dignity  was  founded 
on  purity  of  heart.  His  reputation  was  unspotted.  I 
never  heard  any  one  hint  even  at  any  moral  error  in 
his  life. 

Dr.  Holyoke  was  in  his  seventieth  year  when  I 
went  into  his  study.  He  had  had  a  very  extensive 
practice,  but  he  had  then  contracted  it  so  that  he 
attended  to  his  business  on  foot.  After  a  short  time 
he  allowed  me  to  walk  with  him  and  see  his  patients ; 
a  privilege  for  which  I  have  ever  felt  most  thankful. 
My  intercourse  with  him  was  highly  instructive ;  it 
was  also  most  agreeable.     He  was  extremely  afiable, 


22  INTRODUCTORY. 

and  had  the  simplicity  of  manner  which  belongs  to  the 
true  gentleman.  Withal  he  had  a  playful  humor  and 
a  most  hearty  laugh ;  but  he  never  wounded  any 
man's  reputation.  Erom  my  very  imperfect  delinea- 
tion of  his  character  you  may  judge  how  much  I 
must  have  venerated  and  loved  him  ;  and  I  hope  that 
this  delineation  may  not  seem  to  you  to  have  occupied 
too  much  space. 

"We  belong,  then,  to  a  profession  in  which  there 
have  been  in  every  age  men  whom  we  may  be  proud 
to  call  our  fathers.  But  a  man  whose  father  was 
ennobled  on  account  of  his  high  character  and  great 
services  to  the  cause  of  humanity,  does  not  necessarily 
derive  advantage  from  the  title  which  descends  to 
him.  He  does  so  only  when  he  imitates  the  virtues 
of  his  parent,  and  labors  for  the  common  good.  A 
desire  for  profit  and  reputation  might  be  enough  to 
prompt  him  to  do  all  this  ;  it  would  also  be  good  pol- 
icy. But  he  will  not  do  it  with  a  full  certainty  of 
success  if  he  be  not  influenced  by  still  higher  motives ; 
by  a  true  love  of  science  and  humanity. 

You  must  not  mistake  me.  We  are  not  called 
upon  to  forget  ourselves  in  our  regard  for  others. 
We  do  not  engage  in  practice  merely  from  philan- 
thropy. We  are  justified  in  looking  for  both  profit 
and  honor,  if  we  give  our  best  services  to  our  patients ; 


INTRODUCTORY.  2B 

only  we  must  hot  be  thinking  of  these  when  at  the 
bed-side.  There  the  welfare  of  the  sick  must  occupy 
us  entirely.  The  sea-captain,  in  a  storm,  must  not  be 
thinking  of  the  rich  merchandise  with  which  his  ship 
is  freighted.  His  mind  must  then  be  engrossed  by  a 
regard  to  the  lives  committed  to  his  charge.  Our 
profession  has  attached  to  it  great  labors  and  great 
responsibility.  It  is  for  the  public  good  that  it  should 
hold  out  due  rewards,  so  as  to  attract  to  it  young  men 
of  talents  and  sound  learning.  Such  men,  with  minds 
liberalized  by  scientific  studies,  and  especially  by  the 
study  of  sciences  most  interesting  to  humanity,  may 
be  expected  to  act  from  motives  of  the  highest  order. 
My  excellent  friend,  M.  Louis,  of  Paris,  in  a  letter  to 
me,  says  that  he  looks  upon  a  physician  ''as  holding 
a  sacred  office,  which  demands  greater  sacrifices  than 
are  to  be  made  in  any  other  profession."  No  one 
is  better  entitled  by  his  own  character  than  this 
distinguished  pathologist  to  utter  this  noble  senti- 
ment. 

Before  concluding  this  letter  I  have  a  remark  to 
make  in  reference  to  the  acknowledged  imperfection 
of  our  art.  Are  there  any  in  our  ranks  who  cease  to 
study  it  diligently  on  this  account  ?  This,  surely,  is 
altogether  unjustifiable ;  for,  if  it  is  imperfect,  they 
should  study  to  improve  it.     Besides,  there  is  abun- 


24  INTRODUCTORY. 

dant  reason  and  encouragement  for  every  one  to  con- 
tinue his  studies  as  long  as  he  lives.  Imperfect  as  the 
healing  art  is,  be  assured  of  this,  no  one  man  knows 
all  that  is  knowfi  respecting  it. 


LETTER  II. 

ON  CONDUCT  IN   THE  SICK-KOOM, 

In  this  letter  I  mean  to  treat  of  the  deportment  of 
the  physician  in  the  sick-room,  and  of  the  investiga- 
tion of  the  cases  presented  to  him. 

The  physician  should  enter  the  sick-room  with  the 
feeling  that  he  has  a  serious  duty  to  perform.  He 
must  remember  that  his  countenance,  and  words,  and 
actions  are  closely  watched  by  the  patient  and  by  his 
friends  in  all  cases  of  severe  sickness ;  and,  indeed, 
where,  though  the  disease  is  slight,  the  apprehension 
of  evil  is  great. 

First  of  all,  his  deportment  should  be  calm ;  he 
should  be  sober  without  solemnity,  and  civil  without 
formality.  He  should  abstain  from  all  levity.  He 
should,  indeed,  be  cheerful,  and,  under  proper  circum- 
stances, he  may  indulge  in  vivacity  and  in  humor,  if 
he  has  any.  But  all  this  should  be  done  with  refer- 
ence to  the  actual  state  of  feeling  of  the  patient  and 
of  his  friends.  He  should  avoid  mannerism ;  and 
8 


26  ON   CONDUCT  IN  THE  SICK-ROOM. 

rather  cultivate  the  feelings  which  will  lead  him 
aright,  than  be  thinking  in  detail  of  the  particular 
steps  which  he  should  take.  The  physician  should 
never  exact  attention  to  himself  The  patient  is  the 
central  object  in  the  sick-room,  or  should  be  so.  The 
physician  should  recognize  this,  and,  if  possible,  put 
his  patient  at  his  ease,  so  as  to  facilitate  his  inter- 
course with  him.  As  far  as  possible,  he  should  seek 
information  from  the  patient  himself  If  the  sick  one 
be  an  infant,  or  in  any  way  incapable  of  speaking  for 
himself,  the  inquiries  must  be  addressed  to  the  mother, 
or  to  the  nurse.  Yet  the  conversation  should  relate 
to  the  patient  only.  In  the  same  spirit,  paying  no 
more  attention  to  others  than  decency  requires,  he 
should  proceed  at  once  to  business.  In  this  way,  he 
acquires  the  confidence  of  his  patient,  and  will  be 
most  likely  to  get  at  the  truth  in  respect  to  his  case. 
Now  that  is  a  very  hard  matter,  this  getting  at  the 
truth.  I  have  often  stated  to  pupils  in  the  hospital, 
after  a  hard  struggle  to  get  at  the  truth  in  some  case, 
this  anecdote,  which,  whether  true  or  not,  has  served 
my  purpose.  It  has  been  said  that  when  Sir  Waltei 
Raleigh  was  a  prisoner  in  the  Tower  of  London,  he 
saw  in  the  yard  a  rencontre  between  two  men,  who 
were  strangers  to  him.  He  thought  he  saw  the  whole 
transaction,  and  that  he  knew  which  was  the  aggressor. 


ON  CONDUCT  IN   THE  SICK-EOOM.  27 

He  was  much  incensed  at  the  conduct  of  this  man ; 
and  when  his  keeper  visited  him  he  expressed  his  feel- 
ings in  regard  to  the  afiair.  His  keeper  then  related 
the  whole  story,  and  showed  Sir  Walter  that  he  was 
quite  in  the  wrong  ;  that  the  man  whom  he  called  the 
aggressor  was,  in  truth,  the  innocent  and  injured 
party.  Sir  Walter  then  turned  round,  and,  taking  up 
some  papers,  threw  them  into  the  fire,  saying,  that  he 
had  been  attempting  to  write  a  history,  but,  if  he  had 
been  so  much  deceived  in  what  had  passed  before  his 
own  eyes,  he  could  not  expect  to  tell  the  truth  as  to 
events  of  distant  regions  and  past  times. 

I  would  not  inculcate  by  this  anecdote  that  we  can- 
not arrive  at  the  truth,  but  that  we  are  very  liable  to 
be  deceived,  and  to  adopt  wrong  conclusions  even  as  to 
occurrences  almost  under  our  own  eyes.  It  is  a  great 
part  of  our  business  to  get  at,  and  examine  the  evi- 
dence respecting  the  cases  which  are  under  our  care. 
I  hold  that  a  physician  must  be  quite  as  acute  as  a 
lawyer  in  examining  witnesses.  The  lawyer,  when 
questioning  a  witness,  acts  as  an  advocate,  seeking 
only  for  what  will  support  his  side  of  the  case.  Un- 
happily, the  physician  sometimes  exhibits  the  same 
spirit,  by  seeking  for  what  shall  support  his  own  doc- 
trines. But  his  duty  is  to  examine  the  testimony 
presented  to  him  in  the  spirit  of  a  judge,  seeking  for 


28  ON   CONDUCT  IN   THE   SICK-ROOM. 

truth  only ;  being  careful  not  to  reject  that  which  is 
well  substantiated,  because  he  cannot  understand  it,  or 
because  it  contradicts  his  preconceived  notions.  It  is 
for  facts  that  we  are  to  seek,  —  for  the  actual  phe- 
nomena,—  and  we  must  be  careful  not  to  accept  opinions 
in  lieu  of  them.  Hence,  our  scrutiny  must  sometimes 
be  very  close.  We  must  insist  on  exact  answers, 
though  not  in  a  violent  manner  ;  for  we  must  always 
take  care  not  to  agitate  the  sick  man. 

In  the  investigation  of  a  case,  it  is  best  to  have  a 
method.  It  is  not  necessary  that  we  should  pursue 
this  formally,  but  we  should  have  it  in  mind,  and,  in 
difficult  cases  of  long  standing,  it  may  be  necessary  to 
pursue  it  in  a  somewhat  precise  manner.  The  method 
should  be  such  that  we  may  be  sure  not  to  neglect 
any  point.  Chiefly,  it  should  be  such  as  to  lead 
us  to  an  examination  of  all  the  functions  and  all 
the  organs ;  and  of  the  relation  to  each  other  of  the 
different  affections  of  the  various  parts.  My  own 
plan  has  been  this :  first,  to  examine  the  organic  func- 
tions, then  the  animal  functions,  and  then  those 
relating  to  reproduction  :  following,  thus  far,  the  plan 
of  Bichat.  Under  the  head  of  organic  functions  1 
consider  those  of  assimilation,  formation  and  excretion. 
The  functions  of  assimilation  are  those,  by  which  the 
foreign  substance  is  taken  into  the  organs  of  digestion. 


ON   CONDUCT  IN   THE  SICK-ROOM.  29 

and  all  which  follow  until  the  nutriment  is  conrerted 
into  blood.  The  functions  of  formation  are  those  by 
which  the  solid  organs  are  moulded  and  maintained, 
and  by  which  those  secretions  take  place,  which  are 
employed  for  the  various  purposes  of  the  body.  The 
functions  of  excretion  are  those,  by  which  the  parts  of 
the  food,  not  employed  for  nutrition,  are  carried  off, 
and  those  by  which  the  blood  is  depurated  of  the  ma- 
terials gathered  up  from  the  various  parts  of  the 
body,  where  they  are  no  longer  useful.  The  animal 
functions  are,  first,  those  of  sensation ;  second,  those  of 
the  voluntary  muscles,  and  of  the  organs  of  speech ; 
and,  third,  between  these,  all  the  mental  functions ; 
including  under  this  head  the  emotions  and  passions,  as 
well  as  the  operations  of  the  intellect.  I  need  not 
treat  in  detail  of  the  functions  of  reproduction.  Ordi- 
narily, they  may  seem  not  to  require  special  attention ; 
but  it  is  not  so  as  regards  females  ;  for  it  is  very  often, 
if  not  always,  necessary  to  advert,  with  them,  to  the 
subject  of  menstruation ;  likewise,  in  married  women, 
we  must  know  when  one  is  in  a  state  of  pregnancy, 
or  of  lactation.  In  some  cases,  of  course,  the  principal 
or  primary  disease  is  found  in  the  organs  of  repro- 
duction. 

Having  obtained  a  methodical  history  of  the  func- 
tions, we  must  avail  ourselves  of  the  physical  signs, 
3* 


50  ON    CONDUCT  IN   THE   SICK-KOaM. 

as  well  as  of  the  sensations  of  the  patient,  and  any 
other  testimony,  in  order  to  ascertain  the  state  of  the 
various  organs  of  the  body.  In  regard  to  all  symp- 
toms, we  must  learn  whether  they  are  constant,  or 
occasional ;  and  if  occasional,  whether  they  recur  at 
regular  periods ;  also  whether  two  or  more  occur  in 
any  order  relative  to  each  other.  In  these  inquiries, 
it  is  sometimes  necessary  to  guard  against  suggesting 
symptoms,  when  the  patient  is  full  of  imaginations. 
Hence,  not  only  should  the  physician  avoid  a  rigid 
fornfality,  but  he  should  exercise  due  discretion  in 
the  mode  of  inquiry.  By  having  a  method  in  the 
mind  we  can  more  readily  decide,  when  our  examina- 
tion is  finished,  although  we  do  not  adhere  to  the 
method  in  every  examination. 

The  symptoms  may  be  divided,  in  the  language  of 
the  day,  into  the  objective  and  subjective.  The 
objective  are  those  which  we  discover  by  our  own 
observation  and  examination  of  the  patient.  Such  are 
the  phenomena  of  the  countenance,  the  respiration, 
pulse,  &c.,  &c.  The  subjective  symptoms  are  those 
which  we  must  learn  from  the  patient  himself,  con- 
sisting ill  his  own  sensation,  or  derived  from  his  own 
consciousness.  It  is  obvious  that  the  objective  symp- 
toms are  most  worthy  of  reliance,  because  we  can 
measure  them  for  ourselves,  and  have  one  standard 


ON   CONDUCT   IN   THE   SICK-ROOM.  61 

for  all  patients.  Far  otherwise  with  the  subjective 
symptoms ;  since  patients,  equally  anxious  to  tell  us 
the  truth,  will  describe  their  sensations  in  very  differ- 
ent terms,  when  we  have  reason  to  believe  that  they 
are  the  same,  or  nearly  the  same.  This  difference 
relates,  in  the  first  place,  to  the  degree  of  violence,  or 
severity,  if  it  be  pain  which  the  patient  speaks  of. 
But  there  is  a  greater  difficulty  in  regard  to  the  kind, 
or  quality  of  the  sensations.  We  employ  names  for 
objects  which  are  well  known,  such  as  animals,  plants, 
or  machines ;  but  there  are  many  sensations  which  are 
sufficiently  definite  in  themselves,  and  well  known  to 
those  who  have  experienced  them,  but  which  are  so 
rare  as  not  to  have  acquired  distinct  names.  These 
are  described  by  each  patient  by  such  comparisons  as 
occur  to  his  mind.  But  to  two  different  men,  having 
the  same  feelings,  different  comparisons  will  occur. 
The  two  patients  will  at  first  seem  to  speak  of  different 
things ;  and,  though  the  experienced  physician  will 
generally  discover  what  is  meant,  he  cannot  always  do 
it ;  and  probably,  in  some  instances,  he  is  entirely  mis- 
led. There  are  cases,  in  which  we  find  no  objective 
symptoms,  or  none  of  much  importance,  and  must 
therefore  rely  on  the  patient  alone.  In  such,  this 
absence  of  objective  symptoms  should  be  noted,  as  part 
of  their  history.     It  is  one  of  the  great  accomplish^ 


32  ON   CONDUCT  IN  THE  SICK-EOOM. 

merits  of  modern  physicians  that  thej  learn  so  much 
more,  by  their  own  observations  on  the  patient,  than 
their  predecessors  did.  This  is  instanced  particularly 
in  the  exploration  of  the  thorax  by  auscultation  and 
percussion.  But  I  think  it  is  quite  as  difficult  an  art 
to  collect  and  duly  estimate  the  subjective  symptoms. 
For  this  purpose  one  must  have  a  good  knowledge  of 
human  nature,  be  in  the  habit  of  intercourse  with 
men,  and  be  able  to  estimate  aright  the  scale  on 
which  language  is  employed  by  different  persons. 
Besides  this  difference,  which  arises  from  the  more  or 
less  acute  feelings  of  different  persons,  there  are  others 
which  come  from  the  different  degrees  of  precision 
with  which  men  express  their  ideas,  or  from  the  more 
or  less  extensive  vocabulary  which  they  employ. 
Thus,  the  lawyer,  the  farmer,  and  the  seaman,  would 
describe  their  sufferings  in  very  different  terms, 
although  one  might  not  be  more  acute  than  the  other 
in  his  feelings. 

In  first  examining  a  new  case,  it  is  not  well  to  ask 
what  is  the  disease,  for  that  leads  the  patient  to  give 
his  opinion,  on  which  it  is  not  well  that  he  should  be 
committed ;  or  else,  he  replies,  it  is  that  which  he 
wants  you  to  tell.  It  is  better  to  ask  in  what  way  he 
is  incommoded,  for  that  is  what  he  does  know.  Often- 
times it  is  best  to  let  the  patient  tell  his  story  in  his 


ON   CONDUCT  IN   THE   SICK-ROOM.  33 

own  way,  without  bringing  into  view  your  method 
of  examination.  When  he  has  finished,  you  may 
cross-question  him ;  afterwards  you  may  consider 
how  many  of  the  questions,  which  you  would  have 
asked,  he  has  answered,  and  then  address  to  him  such 
new  ones  as  will  fill  up  the  methodical  examination  of 
his  case.  In  grave  cases,  however,  especidly  when 
of  long  standing  and  obscure,  it  is  best  to  insist  upon 
a  methodical  examination.  It  is  the  shortest  way. 
This  examination  will,  of  course,  include  the  past  his- 
tory, and  the  present  state.  In  many  instances,  one 
interview,  or  even  two,  will  not  suffice  for  this  investi.< 
gation. 

In  subsequent  attendance  on  the  case  it  is  important 
to  watch  the  changes  in  the  past  symptoms,  as  well  as 
to  note  all  new  ones.  Not  unfrequently  we  must 
make  inquiries  of  the  friends  of  the  patient  to  obtain  a 
full  account  of  the  case.  I  state  this  in  order  to  give 
a  caution.  Without  any  bad  intentions,  the  friend  will 
sometimes  mislead  us,  owing  to  his  undue  anxiety  and 
apprehension,  or  because  he  has  adopted  an  hypothesis, 
and,  like  an  advocate,  enlarges  upon  the  evidence  in 
support  of  that.  It  does  happen,  though  rarely,  that 
some  sinister  motive  causes  the  supposed  friend  to 
misrepresent  the  case.  I  would  not  inspire  jealousy 
on  this  subject,  but  only  caution.     In  getting  the  his- 


34  ^      ON   CONDUCT  IN  THE  SICK-EOOM. 

tory  of  the  case  it  is  always  right,  and  sometimes 
quite  essential,  to  get  dates ;  if  possible,  with  accuracy. 
Ascertain  not  only  the  date  of  the  beginning  of  the 
disease,  but  also  that  of  each  prominent  symptom,  and 
of  every  change  which  has  occurred,  good  or  bad.  In 
every  important  case  the  previous  history  of  the 
patient  should  be  ascertained,  in  respect  to  his  own 
health,  and  even  that  of  his  family;  likewise,  his 
habits  as  to  diet,  business,  pleasures,  etc.,  his  temper- 
ament and  disposition,  should  be  ascertained.  If  the 
attack  be  acute,  and,  especially,  if  of  a  nervous  char- 
acter, we  should  ascertain  whether  the  patient  has 
been  subject  to  the  same. 

It  is  thought  quite  essential,  you  know,  that  the 
physician  should  feel  the  pulse,  and  look  at  the 
tongue ;  and  the  objective  signs,  which  we  thus  dis- 
cover, are  often  quite  important.  I  believe  Celsus 
advises  that  we  should  not  be  in  a  hurry  to  feel 
the  pulse.  But  I  have  found  it  better  to  make  this 
examination  early  in  the  visit,  before  the  patient  has 
become  fatigued  or  excited ;  and,  if  there  seems  to  be 
any  emotion  at  that  time,  the  examination  may  be 
repeated  when  the  patient  has  become  calm.  To  see 
the  tongue  fairly,  you  should  sit  between  the  patient 
and  the  light.  I  make  this  minute  remark  because 
this  position  will  enable  you  to  make  other  obser 


ON  CONDUCT  IN  THE   SICK-KOOM.  35 

fations  with  advantage,  such  as  relate  to  the  counte- 
nance, eyes,  complexion,  attitude,  motions  of  the 
chest,  and  of  other  parts ;  and  these  things  may  be 
watched  without  embarrassing  the  patient,  without  his 
being  aware  of  your  object,  if  you  are  so  placed  as  to 
see  him  distinctly.  Let  me  add  to  this  long  detail  as 
to  the  examination  of  the  patient,  that,  in  difficult 
cases,  it  is  necessary  to  review,  consider,  and  digest 
the  evidence,  and  to  repeat  your  examination  until 
you  have  arrived  at  all  the  satisfaction  which  the  cir- 
cumstances permit. 

A  young  physician,  fearful  that  he  may  be  thought 
ignorant,  is  tempted  to  answer  too  readily  the  inquiries 
of  the  patient,  or  his  friends,  as  to  the  diagnosis,  prog- 
nosis, and  the  treatment.  He  will,  however,  ulti- 
mately, gain  by  not  yielding  to  this  temptation. 
Sensible  men,  and  sensible  women  too,  will  give  him 
credit  if  he  takes  time  to  think  before  he  speaks.  I 
would  not  counsel  any  affectation ;  do  not  say  that  the 
case  is  uncertain,  with  a  wiseacre  shake  of  the  head. 
This  will  not  ultimately  advance  your  reputation.  Be 
cautious,  but,  at  the  same  time,  frank  ;  and,  when  you 
have  made  up  an  opinion,  state  it  plainly.  Be  slow 
to  give  an  alarm  as  to  the  result,  especially  to  the 
patient ;  for  to  judicious  friends  it  is  best  to  state  all 
your  apprehensions.     It  is  sometimes  quite  essential, 


36  ON   CONDUCT  IN   THE   SICK-ROOM. 

though  not  so  often  as  you  might  suppose,  to  hide 
your  fears  entirely  from  the  patient,  and  from  anxious 
friends  who  surround  him.  This  is  justified  only 
where  it  is  evidently  for  the  welfare  of  the  sick,  to 
whom,  certainly,  you  ought  not  to  make  your  knowl- 
edge work  an  injury.  Every  one  will  admit  the  pro- 
priety of  this  where  the  mental  powers  are-  impaired. 
But  also  with  young  persons,  whose  minds  are  imma- 
ture, and  with  persons  who  are  morbidly  apprehensive, 
it  is  often  dangerous  to  acknowledge  your  fears.  When 
conscious  that  you  are  influenced  only  by  benevolent 
motives,  and  that  you  'must  deceive  the  patient,  do  it 
thoroughly ;  do  not  try  to  save  yourself  by  equivocal 
expressions.  If  a  patient  of  sane  mind  and  of  adult 
age  demands  your  honest  opinion,  give  it  to  him  dis- 
tinctly ;  even  then  do  not  couch  it  in  the  coarsest 
terms,  but  use  the  mildest  words  which  will  answer 
your  purpose. 

A  common  inquiry  on  the  part  of  the  patient  and 
his  friends  is  as  to  the  cause  of  disease.  To  this 
inquiry  they  are  sometimes  answered  by  the  physician 
in  blind  terms,  which  they  cannot  understand.  It  is 
unworthy  of  a  scientific  man  to  make  a  reply  to  such 
queries  in  terms  which  are  designedly  unintelligible  ; 
and  yet  it  is  often  impossible  to  do  it  in  terms  which 
will  be  properly  understood.    If  a  professor  at  a  clini- 


ON  CONDUCT  IN  THE   SICK-ROOM.  37 

cal  lecture  were  stating  to  his  pupils  his  views  in  such 
a  case,  he  might,  perhaps,  occupy  an  hour  in  so  doing ; 
and  this  to  pupils  so  far  advanced  as  to  understand  the 
scientific  terms  he  would  employ.  How,  then,  can  he 
make  a  brief,  and  at  the  same  time  an  intelligible 
reply  to  a  common  patient  ?  But  there  is  another 
difficulty  which  I  will  not  disguise.  This  is,  that  in 
many  cases  we  do  not  know  the  causes.  Thus,  in 
diseases  of  the  skin,  it  is  often  impossible  to  assign 
the  true  cause ;  that  is,  the  true  efficient  cause.  From 
these  considerations  I  have  thought  it  better  to  avoid 
the  discussion  of  causes  as  much  as  possible,  never 
hesitating  to  avow  that  physicians  are  much  more 
ignorant  on  these  points  than  they  are  supposed  to  be ; 
or,  at  least,  that  this  was  true  in  my  own  case. 

I  have  known  one  physician  who  could  hardly  be 
made  to  answer  any  question,  during  his  visits,  on 
points  not  relating  to  his  patient.  He  was,  perhaps, 
too  dry,  too  stiff.  But  his  course  was  admirable  com- 
pared with  that  of  the  gossiping  doctors,  who  talk  over 
all  the  affairs  of  the  village,  almost  forgetting  the 
patient  immediately  before  them.  I  need  not  point 
out  the  numerous  evils  of  this  course. 

Of  many  cases,  and  even  of  all,  it  may  be  desirable 
to  keep  notes ;  but  there  are  some  evils  attending  this. 
If  the  notes  are  taken  during  the  visit,  they  must  be 
4 


38  ON    CONDUCT   IN   THE   SICK-IIOOM. 

brief,  often  hurried,  and  then  not  worthy  of  reliance. 
If  taken  afterwards,  at  home,  many  circumstance& 
may  be  forgotten.  Taken  during  the  visit,  they  dis- 
tract the  attention,  and  the  physician  puts  his  knowl- 
edge on  paper  without  fixing  it  in  his  mind.  We 
would  desire  that  the  physician  should  give  himself  to 
the  examination  of  his  case,  until  it  should  become 
daguerreotyped  upon  his  mind.  This  is  not  so  likely 
to  be  done,  if  he  is  occupied  Avith  his  pencil  and  his 
note-book.  However,  men  differ  in  their  capacities ; 
and  some  are  able  to  get  the  benefit  of  notes,  without 
the  evils  which  I  have  suggested.  If  you  do  take 
notes,  use  them ;  put  them  in  a  form  to  be  useful. 
Set  down  carefully  all  the  plienomena  —  what  you  do 
not  understand,  as  as  well  as  what  you  do.  Then 
transfer  the  whole  in  a  systematic  manner  to  your 
large  case-book,  at  home.  Review  your  notes  from 
time  to  time  while  the  case  is  going  on,  and,  when  it 
is  finished,  subjoin  to  your  notes  such  reflections  as 
they  may  give  rise  to. 

Your  directions  as  to  medicines,  diet  and  general 
management,  should  be  given  with  great  care.  Make 
them  clear  and  exact,  and  state  whether  they  are  to 
be  followed  literally,  at  all  events,  or  whether  anything 
is  to  be  trusted  to  the  discretion  of  the  attendants. 
In  grave  cases,  or  where  the  drugs  are  potent,  it  is  best 


ON   CONDUCT   IN   THE   SICK-ROOM.  39 

to  put  the  directions  in  writing.  If  possible,  deal 
\Yith  the  real  nurse,  whether  she  be  the  mother  or  a 
nurserv-maid  ;  for  directions,  which  pass  from  one  per- 
son to  another,  are  very  likely  to  be  misstated.  When 
you  make  your  prescription,  settle  in  your  own  mind 
what  direct  effects  are  to  be  expected  from  the  med- 
icine, and  in  what  way  it  is  to  benefit  the  patient. 
Afterwards  note  whether  the  results  are  such  as  you 
had  anticipated,  or  in  what  way  they  have  been  differ- 
ent from  your  expectations.  It  is  in  this  way  you 
can  make  your  experience  beneficial.  It  is  a  grateful 
thing  to  see  your  patient  get  well  in  any  way  ;  but  it 
is  important,  for  those  who  are  to  follow  him,  that  you 
should  know  how  far  your  treatment  had  helped  him, 
or  hurt  him. 

I  said  that  you  should  enter  the  room  of  a  sick 
man  in  a  calm  manner,  and  with  a  sober  air,  showing 
your  desire  to  learn  the  state  of  your  patient.  I 
will  now  add,  that,  if  possible,  you  should  leave  the 
room  with  an  air  of  cheerfulness  ;  such  as  should  give 
all  the  hope,  which  the  case  will  justify,  for  the  com- 
fort of  the  patient  and  his  friends. 

It  is  your  interest,  as  well  as  your  duty,  to  render 
all  the  service  you  can  to  those  who  call  for  your  pro- 
fessional aid.  And,  first,  you  should  attend  to  the 
sails  which  are  made  on  you  with  the  least  possible 


40  ON   CONDUCT   IN   THE   SICK-ROOM. 

delay ;  not,  however,  breaking  an  old  engagement  for 
a  new  one.  Next,  be  punctual  in  your  attendance. 
If  possible,  make  your  visit  when  it  is  expected,  and 
let  it  be  known  when  you  should  be  expected.  Entire 
precision  in  this  respect  is  not  possible ;  but  it  should 
be  approximated.  It  is  proper  to  decide  in  your  own 
mind,  during  one  visit,  when  you  will  make  the  next ; 
for  you  will  then  think  of  all  the  circumstances  which 
should  decide  you,  which  you  might  forget  the  next 
morning.  If  it  is  a  matter  of  indifference,  let  it  be 
known  that  the  time  is  uncertain,  so  that  the  patient 
may  be  saved  from  anxiety,  or  other  inconvenience. 
To  a  man  in  full  practice  these  arrangements  are 
attended  with  difficulty.  But  one  who  realizes  that 
they  are  important  to  the  comfort,  and  sometimes  to 
the  essential  welfare  of  the  patient,  will  be  able  to 
conform  to  them  more  easily  than  might  be  antici- 
pated. 

It  is  proper  for  a  physician,  as  it  is  for  other  men, 
to  take  care  of  his  reputation.  His  success  in  life 
depends  on  it.  He  should,  however,  be  more  ready 
to  meet  any  charge  against  him  on  the  score  of  fidelity 
and  honorable  conduct,  than  on  account  of  skill.  He 
will  sometimes  suffer  from  the  ignorance  of  those  about 
him.  A  stupid  and  tattling  nurse,  or  a  silly  fine 
lady,  may  do  him  real  injury ;  and  this  is  the  more 


ON   CONDUCT  IN  THE   SICK-ROOM.  41 

vexatious  and  mortifying  because  he  cannot  meet  them 
on  fair  grounds.  If  his  skill  is  called  in  question,  he 
cannot  condescend  to  defend  himself  against  such 
assailants.  If  they  circulate  falsehoods,  it  may  be 
necessary  to  expose  them.  But,  if  the  charges  are  not 
grave,  it  is  better  to  disregard  them.  Above  all,  he 
should  not  court  such  persons  as  I  refer  to,  with  a 
view  to  prevent  injury  from  them.  Foolish  friends 
may  do  him  great  harm.  They  may  desert  him ;  but^ 
what  is  worse,  they  may  give  him  injudicious  praise. 
If  he  can  help  it,  he  should  never  let  any  one  cry  him 
up ;  not  even  the  wise  and  -good.  It  must  be  his  wish 
that  such  persons  should  think  well  of  him,  but  not 
that  they  should  give  him  extravagant  praise.  On 
the  whole,  one  need  not  fear  that  he  shall  not  get  suf- 
ficient credit.  I  have  often  remarked  that,  though  a 
physician  is  sometimes  blamed  very  unjustly,  it  is 
quite  as  common  for  him  to  get  more  credit  than  he  is 
fairly  entitled  to ;  so  that  he  has  not,  on  the  whole, 
any  right  to  complain. 
4* 


LETTER  III. 

ON  THE  NERVOUS  SYSTEM  AND  ON  HEADACHE. 

Let  us  now  begin  at  the  head,  and  go  downwards. 
I  shall  not  notice  all  the  diseases  in  the  various  parts, 
but  only  those  on  which  I  have  something  to  say. 

In  the  head  the  most  important  part  is  the  brain, 
and  I  must  connect  my  observations  on  diseases  of 
this  organ  with  those,  which  relate  to  the  whole 
nervous  system.  As  introductory  to  particular  dis- 
eases of  this  system,  I  wish  to  oifer  some  general 
remarks  and  explanations  in  respect  to  its  physiology 
and  pathology. 

To  give  you  my  thoughts  on  the  diseases  of  the 
nervous  system,  I  must  point  out  wherein  it  is  affected 
by  or  through  the  organic  system,  and  where  it  acts 
independently.  To  make  my  views  clear,  I  must 
begin  with  the  simplest  living  beings,  but  I  will  not 
carry  you  minutely  through  the  whole  series  of  vege- 
tables and  animals. 

The  polypus  is  one  simple  organ  ;  a  bag,  of  which 


ON  THE  NERVOUS  SYSTEM  AND  HEADACHE.  43 

the  outside  is  as  good  as  the  inside,  and  vice  versa ; 
and  of  which  one  portion  is  as  good  as  any  other ;  so 
that  you  may  cut  it  in  pieces,  and  each  piece  may  live 
and  model  itself  into  a  perfect  polypus.  The  cellular 
vegetables,  such  as  the  algae,  are  as  simple  in  organi- 
zation as  the  polypus,  or  even  more  so.  They  may 
be  regarded  as  consisting  of  simple  cells,  aggregated 
together,  but  each  capable  of  an  independent  life.  As 
you  ascend,  you  find  in  animals  and  vegetables  distinct 
parts,  or  organs,  destined  for  special  purposes.  Thus, 
in  vegetables,  you  find  a  coating  like  a  skin,  or  a 
bark,  and  you  find  leaves  for  respiration.  You  also 
find  distinct  parts  for  the  perpetuation  of  the  species, — 
the  flowers, —  many  of  them  among  the  most  beautiful 
objects  in  creation.  Yet,  all  that  belongs  to  these 
vegetables  is  for  the  maintenance  of  individual  life, 
and  for  the  perpetuation  of  the  species. 

Here,  then,  we  see,  in  the  simplest  of  living  beings, 
a  capacity  for  forming  such  organs  as  are  needed  for 
their  humble  and  limited  purposes.  It  is  easy  to 
conceive  that  beings,  coming  under  the  same  general 
character,  may  be  able  to  form  other  organs,  for  dis- 
tinct purposes,  not  essential  to  their  own  life,  nor  for 
the  maintenance  of  their  race.  Thus,  the  coral  forms? 
a  matrix  for  itself  and  its  progeny,  and  this  answers  like- 
wise for  its  tomb.     In  this  its  remains,  with  those  of 


44     ON   THE   NERVOUS   SYSTEM   AND   HEADACHE. 

its  contemporaries  and  its  progeny,  continue  bedded 
for  ages,  and  by  their  accumulation  build  up  rocks  in 
the  ocean,  and  give  a  foundation  for  islands.  But  the 
most  simple  instance,  and  one  most  to  my  purpose,  is 
the  thorn  formed  on  plants.  This  seems  to  me  the 
simplest  of  outgrowths.  It  is  formed  by  the  organic 
system  for  its  use  ;  but  it  does  not  perform  any  func- 
tion necessary  for  the  life  of  the  plant,  nor  for  that  of 
its  progeny.  The  naturalist  might  point  out  to  you  an 
abundance  of  like  instances,  and  go  gradually  from 
the  thorn,  through  the  more  complicated  structures, 
to  the  nervous  system  in  man.  Among  animals,  low 
in  the  scale  of  beings,  you  find  nerves.  Rising  in  this 
scale  you  find  a  ring,  or  some  larger  centre,  where 
the  various  nerves  meet,  or  from  which  they  are  falsely 
said  "to  issue ;  and  you  arrive  through  the  ganglia  to 
the  brain,  a  compound  ganglion,  with  the  medulla 
spinalis  attached  to  it.  All  these  are  outgrowths  from 
the  organic  system;  they  are  maintained  in  life  by 
that  system,  and  are  subject  to  the  diseases  which  be- 
long to  it,  such  as  inflammation,  tuberculosis,  &c.  It 
is  perfectly  true  that  the  brain  and  nerves  repay  the 
obligation  to  the  organic  system.  Man  is  not  planted 
in  the  earth  whence  he  may  derive  his  nourishment. 
Thougli  he  gets  one  essential  of  his  life  from  the 
atmosphere  that  surrounds  him,  his  skin  is  not  encom- 


ON  THE  .NERVOUS  SYSTEM  AND  HEADACHE.  45 

passed  by  a  material,  from  which  his  nutriment  can  be 
absorbed.  He  must  seek  and  gather  his  food ;  and, 
to  secure  enough  of  it,  he  finds  it  best  to  cultivate  the 
earth  which  is  to  produce  it.  Thus  the  animal  system 
repays  the  organic  system,  by  which  it  was  built  up, 
and  by  which  it  is  maintained. 

Now,  how  are  all  these  functions,  organic  and 
animal,  performed  ?  As  to  the  organic,  we  can  obtain 
some  notions,  though  in  them  there  is  a  mystery  we 
cannot  solve.  We  get  so  far  behind  the  curtain  as  to 
discover  the  cells,  and  can  trace  their  subdivision  and 
multiplication ;  we  can  see  how  some  are  combined  to 
build  up  the  solid  organs ;  and  we  find  the  secretions 
are  gathered  from  other  cells,  which  open  and  pour 
them  out.  Here  is  something  to  gratify  our  wish  to 
comprehend  the  operations  in  a  living  body,  though 
we  cannot  discover,  from  the  examination  of  any  cell, 
by  itself,  for.  what  purpose  it  is  fitted  —  whether  to 
make  a  bone  or  a  muscle,  saliva  or  bile.  An 
acquaintance  with  the  normal  operations  in  the  organic 
system  enables  us  to  comprehend  something  as  to  its 
abnormal,  or  pathological  operations.  We  find  in  in- 
flammation a  modification  of  the  formative  or  nutri- 
tive processes;  and  in  some  more  grave,  happily 
more  rare,  morbid  aifections,  the  organic  system  appears 
to  form  something  like  new  organs,  Or  structures. 


46  ON  THE  NERVOUS  SYSTEM  AND  HEADACHE. 

These  do  not  conform  to  anything  in  the  healthy  state, 
and  they  cause  a  waste  and  decay  of  the  whole  body. 
Now,  these,  and  other  changes  which  are  wrought  by 
the  organic  system  in  its  own  organs,  may,  some  of 
them  at  least,  be  wrought  in  the  organs  belonging  to 
the  animal  system.  Every  day  we  are  seeing  inflam- 
mation and  tubercles  in,  or  about  the  nervous  organs. 
So  far  we  can  get  at  some  understanding  of  the  diseases 
of  the  nervous  system.  This  system  has  its  functions 
impaired,  or  arrested  in  its  various  organs  by  pressure 
on  them,  especially  when  suddenly  made.  This  is  one 
of  the  effects  of  inflammation.  There  may  also  be 
destructive  diseases  in  the  brain,  or  other  nervous 
organs ;  such  as  softening  —  a  consequence,  as  some 
think,  of  inflammation.  In  these  instances,  if  we  can 
examine  the  parts  affected,  before  or  after  death,  we 
see  the  changes  of  structure  which  have  been  wrought, 
While  some  of  the  diseases  of  the  brain  and  its 
nervous  appendages  are  eiplained,  as  has  been  stated, 
there  are  others  not  to  be  explained  in  the  same  way. 
On  inspection  of  the  organs  concerned,  there  cannot 
be  discovered  any  addition  to,  nor  change  of,  structure. 
Here  we  have  diseases,  of  which  we  know  nothing 
more  than  clinical  examination  discloses.  We  know 
only  the  abnormal  phenomena.  By  studying  the 
symptoms,  their  course,  and  the  order  of  their  occur- 


ON  THE  NERVOUS  SYSTEM  AND  HEADACHE.  47 

rencGj  we  satisfy  ourselves  in  what  part  of  the  nervous 
system  the  morbid  affection  originated ;  but  that  is  all 
we  can  do.  And  now  I  wish  you  to  see  where  the 
difficulty  lies. 

We  know  what  are  the  normal  functions  of  the  ner- 
vous system,  and  we  know  much  of  the  relation  of  its 
various  parts,  or  organs.  We  know  that,  connected 
with  the  nervous  centres,  there  are  many  nerves  lead- 
ing to  every  part  of  the  body.  We  know  that  these 
nerves  are  not  all  adapted  to  the  same  office ;  but  that 
they  perform  various  offices,  quite  distinct  in  their 
nature.  We  have  nerves  of  sense,  nerves  subservient 
to  volition,  those  through  which  an  irritation  in  one 
part  causes  motion  in  another,  &;c.  How  do  the  op- 
erations take  place  in  these  nerves,  and  how  do  they 
differ  from  each  other  ?  How  is  the  image  formed  on 
the  retina  communicated  through  the  optic  nerve  to 
the  brain  ?  Or,  how  is  the  fine  aroma  of  a  rose  con- 
veyed through  the  olfactory  nerve  ?  No  answer  can 
be  given  to  these  questions  in  the  present  state  of  our 
knowledge.  They  say,  men  have,  each  and  all,  a 
right  to  their  opinions,  and  some  one  may  choose  to 
believe  that  vibrations  are  carried  through  the  nerves 
of  sense  to  the  brain.  Let  him  have  his  opinion,  and 
then  beg  him  to  explain  why  visual  objects  cannot  be 
discovered  through  the  ear,  or  sounds  through  the  nose. 


48   ON  THE  NERVOUS  SYSTEM  AND  HEADACHE. 

It  must  be  allowed,  I  think,  that  there  is  a  specific 
difference  in  the  action  of  the  nerves  connecting  the 
different  organs  of  sense  and  the  brain ;  and  a  further 
examination  of  the  subject  would  show  that  there  must 
also  be  a  difference  between  nerves  of  sense  and  those 
sent  to  the  muscles,  each  having  specific  powers  and 
modes  of  action,  or  operation.  But  we  cannot  point 
out  what  their  actions,  or  operations  are  in  any  one  of 
the  cases  of  nervous  influence.  We  do  not  know  how 
any  of  the  natural,  normal,  or  healthy  operations  in 
the  nervous  system  take  place. 

If  I  have  succeeded,  you  are  prepared  for  my  corol- 
lary, which  is  this :  the  nervous  system  may  undergo 
important  changes  in  its  functions,  the  effects  of  which 
are  perfectly  and  abundantly  manifested,  while  we 
cannot  ascertain  in  what  those  changes  consist.  If  we 
cannot  show  the  difference  in  the  operations  of  the 
olfactory  and  optic  nerves,  we  cannot  expect  to  dis- 
cover the  difference  in  the  healthy  and  the  morbid 
operations  which  occur  in  the  brain  and  its  appendages. 
You  will  understand  that  I  refer  here  to  cases  where 
no  change  of  structure  is  to  be  discovered  in  the  part 
affected,  and  where  there  is  not  any  morbid  change  in 
any  other  part  of  the  body  acting  on  the  diseased  brain 
and  nerves.  ; 

I  am  aware  of  a  resource  for  the  explanation  of 


ON  THE  NERVOUS  SYSTEM  AND  HEADACHE.  49 

nervous  affections  among  those,  who  cannot  endure  to 
be  ignorant  of  anything,  or  who  will  not  avow  their 
ignorance.  They  will  resort  to  the  more  or  less. 
They  will  tell  you  there  is  too  much  tone,  or  strength, 
in  the  part,  or  too  little ;  or  those  who  would  be  more 
definite,  will  compare  the  nervous  power,  calling  it  a 
fluid,  to  the  electric  power  or  fluid.  These  persons 
will  tell  you  that  there  is  an  accumulation  of  nervous 
fluid  in  a  particular  part  in  one  case,  and  a  deficiency 
of  the  same  fluid  in  another.  I  will  not  spend  words 
in  sifting  this  and  similar  explanations,  but  will  say, 
dogmatically,  they  come  to  nothing. 

I  arrive  at  the  conclusion  that  many  morbid  affec- 
tions of  the  nervous  system  do  not  admit  any  explana- 
tion in  the  present  state  of  our  knowledge ;  and  that 
our  treatment  of  the  same  is,  and  must  be,  founded 
entirely  on  experience ;  I  may  say,  perhaps,  a  blind 
experience. 

Let  us  now  proceed  to  the  diseases  of  the  head. 
Among  these  we  may  first  consider  Headache. 
This  occurs  as  one  of  the  symptoms  in  many  diseases, 
where  the  whole  system  is  involved,  such  as  fevers. 
But  headache,  independent  of  these,  is  of  several  kinds. 
Among  these  is  one  commonly  known  as  the  Sick- 
Headache.  This  affection  is  various  in  its  degree, 
and  in  the  frequency  of  its  occurrence.  To  some 
5 


60  ON  THE  NERVOUS  SYSTEM  AND  HEADACHE. 

persons  it  is  a  very  sore  evil,  not  onlj  from  the  suffer- 
ings which  belong  to  it,  but  because  it  occupies  so 
large  a  portion  of  their  time.  As  it  may  occur  at  any 
moment,  such  persons  are  scarcely  able  to  make  any 
engagements  without  bargaining  that  they  shall  be 
excused  if  they  have  the  headache.  I  think  I  have 
known  some,  who  have  suffered  from  this  disease  from 
one  quarter  to  one  third  of  the  time,  for  several  years 
in  succession.  I  believe  that  this  disease  occurs  even 
in  early  childhood ;  more  commonly  it  is  not  noticed 
until  after  the  age  of  puberty.  Having  once  occurred, 
it  often  increases  in  severity  and  in  frequency,  to  the 
age  of  forty  or  even  later.  It  usually  diminishes  at, 
or  before,  fifty,  and  ceases  before  sixty.  This  disease 
seems  to  me  to  be  one  of  the  affections  of  the  brain 
proper.  The  prominent  symptoms  are  pain  in  the 
head  and  nausea,  to  which  vomiting  is  often  added ; 
and  the  first  impression  is  that  it  is  produced  by  in- 
digestion, or  what  is  called  a  disordered  stomach.  It 
very  certainly  is  provoked,  in  many  instances,  by 
errors  of  diet ;  but  it  is  provoked  also  by  other  causes, 
such  as  the  air  of  a  close  room,  over-labor,  or  any 
derangement  of  the  body  or  mind.  The  duration  of 
its  fits  is  various.  In  many  persons,  coming  on  in  the 
day,  it  is  relieved  by  a  night's  sleep ;  but  in  some  it 
continues  two,  and  even  three  or  four  days.    It  varies  as 


ON  THE  NERVOUS  SYSTEM  AND  HEADACHE.   51 

to  its  intensity  :  some  persons  continue  their  attention 
to  business ;  while  to  others  this  is  almost  impossible. 
Some  even  must  resort  to  the  bed,  and  remain  in  dark- 
ness and  silence  till  the  fit  is  over.  It  is  hardly 
necessary  to  describe  the  paroxysm  minutely.  In 
some  persons  it  begins  with  a  blind  turn,  scotoma. 
Most  usually  anorexia^  as  well  as  nausea,  attends  it. 
In  others,  however,  the  appetite  is  not  entirely  de- 
stroyed;  and  these  can  take  a  little  food,  not  only 
without  injury,  but  even  with  advantage. 

Under  so  much  suffering,  the  patient  calls  for  relief. 
Occasionally  some  advantage  is  gained  at  the  begin- 
ning by  draughts  of  warm  water,  or  of  weak  chamo- 
mile tea,  so  as  to  promote  vomiting.  Where  the 
nausea  is  urgent  these  may  be  tried  ;  but  ipecacuanha 
and  other  emetic  drugs  should  be  avoided.  Even 
when  they  give  temporary  relief,  they  are  ultimately 
injurious  to  the  stomach.  This  is  not  manifest  in  a 
single  instance,  but  becomes  very  much  so  when  the 
emetic  is  frequently  repeated.  In  those  persons  in 
whom  the  paroxysm  is  usually  long,  if  constipation  of 
the  bowels  exists,  some  laxative  may  be  employed  with 
advantage.  Aloes  is  among  the  best  articles  for  this 
purpose,  unless  forbidden  by  the  existence  of  haemor- 
rhoids, or  by  other  reasons  Sometimes  strong  coffeo 
will  afford  relief.     Some  persons  employ  opium ;  and, 


52  ON  THE  NERVOUS  SYSTEM  AND  HEADACHE. 

as  they  think,  with  benefit.  But,  when  the  paroxysms 
are  frequent,  much  evil  may  be  produced  by  this  article. 
In  these  later  days  ether  by  inhalation  has  been  tried 
with  occasional  relief;  but  I  have  not  had  opportuni- 
ties for  testing  this  fully. 

In  a  large  proportion  of  cases  active  treatment  may 
be  omitted,  as  the  disease  soon  subsides  of  itself;  but 
in  all  cases  the  means  of  prevention  must  be  studied. 
To  this  end,  we  must  endeavor  to  discover  the  exciting 
causes  of  the  paroxysm.  These  may  be  sought  first  in 
the  food  which  is  taken.  The  gross  errors  of  diet  are 
readily  discovered ;  but  in  some  persons  the  headache 
is  occasioned  by  articles  which  may  commonly  be 
taken  with  impunity.  A  peculiar  instance  of  this 
sort  came  under  my  notice  many  years  since.  A 
gentleman  of  a  philosophical  mind,  and  who  was 
moderate  in  all  things,  sufiered  much  from  sick-head- 
ache. He  kept  notes  of  its  occurrence,  and  for  some 
time  before  the  period  to  which  I  am  to  refer,  he  was 
attacked  by  it  about  once  in  a  fortnight.  Being  called 
away  from  home,  he  made  his  dinner  at  a  country 
tavern  on  bread  and  cheese.  This  was  followed  by  a 
Y6ry  severe  headache.  He  now  suspected  the  cheese 
to  have  caused  the  disease,  though  previously  he  had 
felt  confident  that  this  article  always  agreed  with  him, 
and  he  used  it  often.     He  abstained  from  cheese,  and 


ON  THE  NERVOUS  SYSTEM  AND  HEADACHE,  53 

had  no  recurrence  of  the  headache  for  eighteen 
months,  when  it  took  place  after  eating  a  mince  pie. 
I  state  this  instance  as  showing  that  every  article  of 
diet  should  be  suspected  in  turn ;  and,  by  experiment, 
we  should  ascertain  what  articles  are  in  fault.  But 
though  errors  in  diet  are  a  very  common  cause  of  the 
paroxysm,  they  are  not  the  essential  cause ;  at  least,  I 
believe  so.  In  some  persons,  willing  to  make  the 
trials,  I  have  varied  the  diet  in  every  way,  as  to  quan- 
tity and  quality,  and  yet  the  disease  has  continued. 

In  the  largest  number  of  cases  this  disease  begins  to 
grow  more  mild,  and  the  paroxysms  less  frequent, 
before  the  age  of  fifty.  If  it  continues  to  a  later 
period,  without  any  alleviation,  there  is  ground  to 
anticipate  some  more  grave  disease  of  the  brain.  In 
one  instance  of  this  sort  there  took  place  an  affection 
of  the  brain,  which  terminated  in  death,  in  which  I 
thought  there  was  reason  to  suspect  hypertrophy  of 
the  brain.  The  truth  of  this  opinion  was  not  tested 
after  death,  as  the  patient  was  at  a  distance  from  me. 
In  another  case  hemiplegia  occurred.  In  both  in- 
stances the  patients  were  females,  between  sixty  and 
seventy  years  of  age.  One  was  married,  and  had  had 
a  large  family ;  the  other  was  single,  and  had  led  a 
regular  life.  Both  were  well  formed  and  naturally 
vigorous.  Of  course,  I  do  not  pretend  to  draw  a 
5* 


54     ON   THE   NERVOUS   SYSTEM   AND   HEADACHE. 

positive  inference  from  two  cases.  These  are  the  two 
strongest  cases  I  have  known,  but  I  have  seen  others, 
where  slighter  evidence  favored  the  same  conclusion. 

I  referred  to  care  of  the  diet  as  one  mode  of  pre- 
vention. But  all  the  hygienic  rules  should  be  care- 
fully regarded  by  those,  who  are  afflicted  with  this 
troublesome  disease.  What  those  rules  are  I  may 
take  some  other  occasion  to  state. 

There  is  another  headache,  affecting  only  one  side, 
and  occurring  in  paroxysms  of  a  few  hours  daily, 
which  is  called  Intermittent  Hemicrania.  This  is 
the  only  regular  intermittent  disease,  which  is  com- 
mon in  this  vicinity.  In  some  instances  tlie  parox- 
ysms are  more  severe  on  the  alternate  days.  It  is 
usually  connected  with  catarrh  in  the  head,  and  is 
more  frequent  when  the  influenza  prevails  than  at  any 
other  time.  In  a  few  instances  the  pain  is  on  both 
sides  of  the  head,  but  the  great  and  severe  pain  is  still 
limited  to  one  side.  It  has  seemed  to  me,  when  the 
pain  was  on  both  sides,  that  it  is  a  general  headache, 
accompanying  the  intermittent  headache,  as  it  might 
any  other  disease ;  and,  in  accordance  with  this,  when 
the  violence  of  the  disease  abates,  the  general  headache 
goes  off,  leaving  the  hemicrania.  I  have  made  this 
statem.ent,  because  this  pain  on  both  sides  may  leave 
a  doubt  as  to  the  diagnosis.     The  pain  is  about  the 


ON  THE  NERVOUS  SYSTEM  AND  HEADACHE.  55 

temple,  or  around  the  eje,  or  both ;  sometimes  ex- 
tending towards  the  top  of  the  head.  In  one  instance 
onlj  I  have  found  the  pain  in  the  back  part  of  the 
head,  still  limited  to  one  side.  The  paroxysm  usually 
begins  before  noon,  and  not  unfrequently  early  in  the 
morning ;  but  rarely  if  ever  before  sunrise.  Its  dura- 
tion varies  from  three  hours,  to  ten  and  even  twelve. 
The  severity  of  the  pain  also  varies,  but  in  most 
instances  it  is  very  intense,  a  part  of  the  time  at  least, 
so  as  to  entirely  interrupt  an  attention  to  business ; 
and  it  very  often  drives  the  patient  to  his  bed,  in  a 
dark  room.  The  stoutest  and  boldest  men  give  up 
to  it. 

The  duration  of  the  whole  disease  is  as  much  as 
three  weeks  in  all  cases,  and  sometimes  much  more. 
I  once  saw  a  case  which  had  lasted  three  months,  and 
which  was  entirely  relieved  by  treatment  in  five  or 
six  days.  I  speak  less  certainly  about  the  ordinary 
duration,  because  the  cases  I  have  seen  have  uniformly 
been  treated  by  medicine,  and  have  terminated  in  less 
than  three  weeks ;  even  in  one  week  when  attended 
to  from  the  first. 

There  are  some  few  persons,  in  whom  I  have  known 
this  disease  to  occur  repeatedly.  These  have  been 
persons  of  strumous  or  tuberculous  constitutions. 

This  is  one  of  the  very  few  diseases  in  which  I  can 


56  ON  THE  NERVOUS  SYSTEM  AND  HEADACHE. 

venture  to  say  that  it  may  certainly  be  removed  by 
medicine.  The  treatment  is  the  same  as  for  intermit- 
tent fever.  I  have  employed  the  cinchona  in  the 
earlier  part  of  my  life,  and  subsequently  the  sulphate 
of  quinia ;  likewise,  both  formerly  and  latterly,  I  have 
employed  the  solution  of  the  arsenite  of  potash.  This 
last  I  found  much  more  convenient,  at  least,  than  any 
preparation  of  cinchona,  before  the  introduction  of 
quinia  ;  and  I  may  say  that,  were  it  not  for  a  reluct- 
ance to  use  metallic  articles,  and  especially  one  which 
has  so  bad  a  name,  I  should  employ  it  in  most  instances 
at  the  present  day.  Whichever  article  is  employed, 
it  should  be  given  in  as  large  a  dose  as  the  patient 
can  conveniently  bear.  In  giving  the  quinia,  I  ad- 
minister it  only  during  the  intermission.  For  an 
adult,  I  first  order  twelve  to  sixteen  grains  during 
this  period,  and  in  the  next  intermission  increase  the 
quantity  to  a  scruple,  and  go  on  to  increase  it  until 
the  buzzing  of  the  ears,  or  sense  of  tension  in  the  head, 
shows  that  the  dose  is  sufficient.  Subsequently,  I 
keep  at  as  large  a  dose  as  can  be  borne  without  much 
inconvenience,  until  the  patient  has  passed  the  periods 
of  two  paroxysms  without  any  return  of  the  pain. 
The  sulphate  is  given  in  divided  doses,  but  as  the 
intermission  usually  includes  the  night,  and  sometimes 
the  night  only,  it  is  most  convenient  to  make  each 


ON  THE  NERVOUS  SYSTEM  AND  HEADACHE.  57 

dose  large.  In  using  the  arsenic,  I  have  not  found  it 
necessary  to  regard  the  period  of  intermission,  but 
have  exhibited  it  morning  and  evening,  and  in  very 
severe  cases,  if  the  patient  is  not  delicate,  I  have  given 
it  at  noon  likewise.  Prom  five  to  seven  drops  of  the 
solution  may  be  given  at  first,  and  each  dose  may  be 
augmented  by  one  drop,  until  some  nausea  is  pro- 
duced. Then  the  dose  may  be  diminished  by  two 
drops,  and,  if  this  does  not  occasion  nausea,  the  same 
may  be  continued  until  the  patient  has  been  well  two 
days.  Each  dose  of  the  solution  should  be  diluted  by 
at  least  one  tablespoonful  of  soft  or  pure  water. 

I  have  been  thus  minute  as  regards  the  administra- 
tion of  these  articles,  because  I  have  found  that  relief 
has  not  been  obtained  by  those  of  my  brethren,  who 
have  not  regarded  the  rules  which  I  have  mentioned. 

There  is  another  headache,  which  we  often  meet 
with,  called  the  Chronic  Headache.  Probably  all 
the  cases  which  pass  under  this  name  are  not  strictly 
the  same  in  kind ;  but  if  they  would  admit  of  any 
classification,  it  is  not  known  to  me.  The  pain  in 
chronic  headache  is  sometimes  limited  to  the  forehead, 
but,  I  believe,  it  more  frequently  extends  over  the 
whole  or  nearly  the  whole  of  the  head.  This  pain 
appears,  in  some  cases,  to  be  constant ;  in  others,  it  is 
seldom  absent  during  a  whole  day.     It  may  continue 


58  ON  THE  NERVOUS  SYSTEM  AND  HEADACHE. 

many  weeks,  many  months,  and  even  many  years. 
It  would  appear  to  be  very  severe  in  some  cases  ;  yet 
it  does  not,  ordinarily,  oblige  the  patient  to  relinquish 
his  employments.  This  headache  is  not  necessarily 
attended  by  any  other  derangement  in  the  body,  nor  in 
the  mind.  Sometimes  it  takes  away  the  cheerfulness, 
or,  at  least,  prevents  all  gayety ;  but  this  is  far  from 
being  true  in  all  instances.  I  have  had  one  patient, 
who  was  among  our  most  active  business  men,  who 
suffered  under  this  complaint  for  many  years,  not  less, 
certainly,  than  twenty.  During  this  time,  he  em- 
ployed the  remedies,  which  I  directed,  both  medicinal 
and  hygienic,  without  benefit.  He  went  abroad,  and 
obtained  the  best  medical  aid  he  could  find  in  London ; 
and  he  consulted  likewise  more  than  one  medical  man 
among  ourselves.  By  the  advice  of  one  English 
physician,  he  kept  a  seton  in  his  neck  for  several 
months ;  but  neither  this  nor  any  other  treatment 
afforded  him  any  relief  In  this  instance,  as  in 
many  others,  attended  by  obscurity,  each  physician 
was  ready  to  suspect  the  existence  of  his  own  pet 
*nalady.  Accordingly,  one  thought  he  was  bilious, 
another  that  he  was  simply  dyspeptic,  another  that  he 
needed  tonics,  and  anotlier  that  there  was  some  low 
inflammation  within  the  cranium,  or  at  least  a  deter- 
mination of  blood  to  the  head.     Ought  not  a  case  of 


ON  THE  NERVOUS  SYSTEM  AND  HEADACHE.  69 

this  sort  to  be  considered  as  an  affection  purelj 
nervous,  according  to  the  principles  suggested  in  the 
beginning  of  this  letter  ? 

In  every  case  of  chronic  headache  it  is  certainly 
proper  to  examine  closely  and  repeatedly  all  the  func- 
tions of  the  body,  and  the  state  of  mind,  to  ascertain 
if  there  is  any  cause  on  which  the  pain  depends  ;  and, 
if  so,  whether  this  cause  can  be  removed.  There  is 
one  set  of  cases,  in  which  the  pain  in  the  head  obvi- 
ously depends  on  an  affection  of  another  part  of  the 
system.  I  refer  to  the  cases,  not  very  rare,  where  it 
occurs  in  children,  during  the  period  of  their  second 
dentition.  Of  this  more  hereafter.  I  believe  that  some 
derangements  of  the  uterus,  or  ovaries,  may  give  rise 
to  this  headache  in  females.  It  is  among  the  concom- 
itants of  pregnancy  in  rare  instances.  I  had  one 
patient  who  recognized  this  affection  as  the  evidence 
of  pregnancy,  just  as  most  women  do  the  occurrence 
of  nausea  and  vomiting  in  the  morning. 

In  regard  to  the  treatment,  I  have  very  little  to 
say.  If  the  disease  can  be  traced  up  to  an  affection 
of  the  digestive  organs,  or  of  any  other  part  of  the 
system,  the  appropriate  remedies  will  suggest  them- 
selves. Otherwise,  I  can  advise  nothing  better  than 
a  tranquil,  though  not  an  idle  life  ;  simple  but  nutri- 
tious food,  exercise  in  the  open  air,  as  freely  as  it  can 


60  ON  THE  NERVOUS  SYSTEM  AND  HEADACHE. 

be  bornGj  and  a  due  regard  to  all  the  other  hygienic 
rules. 

There  are  other  headaches,  besides  those  I  have 
enumerated,  but  none  on  which  I  have  any  special 
remark  to  offer 


LETTER  IV. 

ON  EPILEPSY  AND   THE   CONVULSION-FITS  OF  YOUNG 
CHILDREN. 

Next  among  the  diseases  which  we  refer  to  the 
head,  I  have  something  to  oiSer  upon  epilepsy.  This, 
you  know,  is  a  disease  which  occurs  in  fits,  or  parox- 
ysms ;  and  these  take  place  after  very  short  warnings, 
or  without  any,  so  that  often  the  patient  falls  down 
suddenly.  Hence  these  are  CQWed  falling  Jits.  The 
essential  symptoms  are  loss  of  consciousness,  and 
spasms  more  or  less  severe  and  extensive.  Most  fre- 
quently, if  not  always,  the  head  is  drawn  to  one  side 
with  a  twitching  motion ;  a  circumstance  on  which  Dr. 
Marshall  Hall  lays  great  stress.  Biting  the  tongue, 
and  frothing  at  the  mouth,  often  colored  with  blood, 
are  common  attendants.  The  duration  of  the  parox- 
ysm varies,  from  a  few  mmutes  to  several  hours.  It 
does  not,  however,  often  exceed  half  an  hour,  except 
in  the  variety  called  apoplectic.  When  the  spasms 
cease,  and  the  consciousness  is  restored,  the  patient 
6 


62  ON   EPILEPSY   AND    CONVULSION-FITS. 

does  not  at  once  recover  the  full  use  of  his  mind,  but 
commonly  falls  into  a  heavy  sleep,  from  which  he 
awakes  with  a  stupid  headache.  Then,  in  a  few 
hours,  or  at  most  after  a  day,  jou  will  find  him  quite 
restored  to  his  ordinary  state.  In  bad  cases  the  intel- 
lectual powers  are  gradually  lost,  and  especially  the 
memory.  Sometimes  a  child,  affected,  for  instance, 
at  six  years  of  age,  continues  to  grow  in  body,  and 
becomes  a  man  in  appearance,  while  his  mind  has 
made  scarcely  any  advance.      The  loss  of  memory 

was  most  remarkable  in  Mr.  P ,  who  belonged  to 

a  family  distinguished  for  their  intellectual  powers. 
He  had  this  disease  for  many  years  without  any 
marked  change  in  his  mind,  except  only  as  to  mem- 
ory. About  the  time  when  the  first  Napoleon  became 
Emperor  of  France,  some  reference  was  made  to  him ; 

upon  which  Mr.  P inquired  who  he  was.     His 

friend  stated  to  him  briefly  the  history  of  Bonaparte, 
in  such  language  as  most  men  would  have  used  at 
that  day  respecting  one  who  seemed  to  aim  at  uni- 
versal empire.     Mr.  P then  said  he  jsould  not 

believe  that  story ;  that  no  man  could  be  so  bad.  At 
this  time  Mr.  P must  have  been  hearing  of  Bona- 
parte every  day  for  several  years. 

Besides  the  paroxysms  which  I  have  briefly  de- 
scribed, many  persons,  subject  to  this  disease,  have 


ON   EPILEPSY  AND   CONVULSION-FITS.  63 

very  slight  affections,  which  are  called  faint  turnSj 
or  by  other  names.  In  some  of  them  you  see  very 
little,  if  any,  change  of  the  countenance.  In  others, 
the  face  turns  pale,  and  then  becomes  very  red,  and 
the  whole  is  over  in  a  minute  or  less.  The  shortness 
of  the  duration  of  these  turns ^  in  some  persons,  is 
very  remarkable.  I  had  one  patient,  who  experienced 
them  very  often,  when  walking,  or  when  engaged  in 
conversation,  while  those  around  him  discovered  no 
change  in  his  appearance.  The  patient  described  them 
as  consisting  of  a  stoppage  of  all  action  of  the  mind, 
analogous  to  stoppage  of  light  to  the  eye  by  bringing 
a  dense  body  momentarily  before  it. 

I  believe  that  no  patient  has  recovered  from  the 
epilepsy,  in  whom  I  have  seen  it  associated  with  these 
slight  turns. 

A  more  grave  affection  connected  with  epileptic 
paroxysms  is  insanity.  In  asylums  for  the  msane 
you  will  usually  find  instances  of  this  kind. 

I  referred  to  apoplectic  epilepsy^  which  has  been 
described  by  Dr.  Marshall  Hall.  It  resembles  apo- 
plexy in  its  general  characters,  though  the  fit  is  accom- 
panied by  more  spasms  than  usually  attend  apoplexy. 
But  this  last  is  ordinarily,  if  not  always,  attended  or 
followed  by  some  paralytic  affection.  This  is  not  true 
of  apoplectic  epilepsy.     Besides,  this  affection  returns 


64  ON   EPILEPSY   AND    CONVULSION-FITS. 

again  and  again,  though  much  less  frequently  than 
the  common  epilepsy.  I  had  noticed  this  kind  of 
epilepsy  before  reading  Dr.  Hall's  work,  and  have  a 
recollection  of  four  well-marked  instances  of  it.  In 
three  of  them  I  believe  every  paroxysm  was  of  the 
apoplectic  character.  In  one,  the  first  paroxysm  was 
of  this  character,  and  the  last ;  but,  between  these, 
epilepsy  appeared  in  its  common  form.  In  each  of 
these  instances  the  patient  died  apoplectic,  but  not  till 
after  several  years  from  the  first  attack.  There  was 
not  in  either  case  a  post-friortem  examination. 

Since  I  have  been  engaged  in  writing  these  letters, 
I  have  seen,  in  consultation,  a  patient,  who  has  been 
subject  a  year  or  more  to  the  apoplectic  epilepsy.  I 
mention  his  case  because  I  find  that  he  is  occasionally 
afiected  by  the  slighter  attacks,  which  I  have  described 
under  the  name  of  faint  turns.  It  is  the  only  in- 
stance in  which  I  have  known  these  to  occur  in  con- 
nection with  the  apoplectic  epilepsy. 

Epilepsy  is  spoken  of  as  if  it  often  terminated 
fatally.  It  undoubtedly  shortens  life  in  most,  if  not 
in  all  instances  ;  but  I  have  rarely  seen  life  terminated 
directly  by  this  disease.  Epileptic  patients  will  have 
many  successive  paroxysms,  and  die  shortly  after- 
wards ;  that  is,  within  a  few  days,  or  a  week  or  two. 
But,  I  believe,  in  these  cases,  there  is  some  other  dis- 


ON   EPILEPSY  AND    CONVULSION-FITS.  65 

ease,  which  is  ushered  in  by  the  epileptic  attacks. 
Here  the  epileptic  paroxysms  take  the  place  of  chills, 
which  are  the  common  precursors  of  acute  diseases. 
The  symptoms  of  the  acute  diseases  in  such  cases  are 
usually  masked  by  epilepsy.  I  wish  not  to  speak  too 
confidently  on  this  point ;  but  this  is  the  opinion  to 
which  my  own  experience  has  led  me. 

The  proximate  cause  of  epilepsy  certainly  exists  in 
the  nervous  system,  the  brain  and  medulla  spinalis. 
The  nature  of  this  affection  of  the  nervous  system  is 
unknown,  and  not  such  as  necessarily  to  leave  any 
organic  changes  manifest  after  death.  I  must  refer 
here  to  my  remarks  on  diseases  of  the  nervous  system, 
in  the  last  letter.  Organic  changes  have  been  found 
in  the  brain  after  epilepsy;  but  they  have  been 
various  in  their  seat,  if  not  in  their  nature,  and  must, 
I  think,  be  regarded  as  coincidents,  and  not  as  proxi- 
mate causes  of  the  disease.  I  do  not  mean,  however, 
.that  they  have  had  no  connection  with  the  peculiar 
affection  belonging  to  epilepsy,  in  the  instances  in 
which  they  have  occurred.  I  am  aware  that  at  the 
present  day  pathologists  are  disposed  to  believe  that 
some  morbid  state  of  the  blood  may  be  regarded  as  an 
irritant,  operating  on  the  nervous  system,  to  produce 
this  disease.  I  would  not  neglect  inquiries  connected 
with  this  view,  but  we  must  be  very  cautious  not  to 
6* 


66  ON  EPILEPSY  AND   CONVULSION-FITS. 

follow  the  practice  of  the  old  humoralists  in  imagining 
a  change  of  this  nature  as  the  cause  of  every  obscure 
disease. 

The  exciting  causes  of  epilepsy  are  better  known 
than  the  proximate  cause ;  yet  we  cannot,  in  every 
instance,  satisfy  ourselves  as  to  those.  It  would  seem 
that  any  cause,  disturbing  the  body  or  the  mind,  in 
an  epileptic  subject,  may  give  rise  to  a  paroxysm. 
Errors  of  diet  are  among  the  causes  most  commonly 
noted ;  great  fatigue  is  also  among  the  causes.  In  a 
young  girl,  in  whom,  perhaps,  the  disease  partook  of 
the  hysteric  character,  paroxysms  followed  the  occur- 
rences which  I  will  mention.  When  she  was  at  a 
party  with  her  little  friends,  where  her  spirits  were 
much  excited,  and  at  the  same  time  her  food  was  less 
simple  than  common,  the  paroxysm  was  apt  to  occur. 
General  Jackson,  when  president,  made  a  visit  to 
this  part  of  the  country,  and  she  went,  with  others,  to 
see  the  procession,  as  he  passed  through  her  town ;  a 
paroxysm  followed.  So  did  another  upon  seeing  the 
'•  Conflagration  of  Moscow,"  an  exhibition  well  known 
at  the  period  of  her  youth.  Again,  she  had  a  parox- 
ysm on  going  into  a  crowd  in  a  church,  where  an 
ordination  was  taking  place.  These  were  among  the 
occasions  which  I  call  to  mind ;  and  from  them  you 
see  the  variety  in  the  exciting  causes  of  this  disease. 


ON   EPILEPSY  AND   CONVULSION-FITS.  67 

A  fright  has  been  repeatedly  noticed  as  occasioning  a 
paroxysm.  I  remember  one  instance,  of  a  ladj,  past 
middle  life,  whose  health  had  been  good  until  a  sudden 
fright  occurred,  which  was  followed  by  epilepsy. 
From  this  time  the  disease  continued.  I  saw  her 
many  years  afterwards,  and  then  the  powers  of  the 
mind  were  much  impaired,  although  not  lost. 

I  believe  that,  in  a  certain  proportion  of  the  cases 
of  epilepsy,  the  disease  is  susceptible  of  relief,  so  as 
not  to  return  without  the  operation  of  some  powerful 
cause.  This  relief  is  not  to  be  attained  by  any  medi- 
cine with  which  I  am  acquainted,  but  by  diet.  The 
diet,  which  I  have  directed  with  success,  has  been 
almost  purely  vegetable.  I  have  directed  an  entire 
abstinence  from  flesh  and  fish,  but  have  allowed  the 
use  of  milk  and  butter,  and  occasionally  of  eggs.  I 
have  thought  it  necessary  to  use  these  last  watchfully; 
that  is,  in  moderate  quantity,  mixed  with  farinaceous 
substances,  as  in  puddings,  and  at  those  times  only 
when  the  health  was  at  the  best.  I  was  led  into  the 
use  of  this  diet  gradually;  I  hardly  remember  by 
what  steps.  Under  the  use  of  it  I  have  seen  many 
recoveries ;  yet,  in  the  larger  proportion  of  cases,  it 
I'las  failed.  But  to  this  I  must  add,  that  I  have  not 
known  an  instance  where  the  patient  has  ultimately 
recovered  after  trying  this  diet  without  success.  Now, 


68  ON  EPILEPSY  AND   CONVULSION-FITS. 

cf  the  cases  in  which  it  has  failed,  probably  every  one 
employed  various  remedies,  not  only  under  my  direc- 
tion, but  under  that  of  others,  and  those,  skilful  physi- 
cians. Every  medical  man  knows  that  in  this  dreadful 
disease,  when  long  continued,  the  patient  or  his  friends 
resort  to  every  one  who  holds  out  a  prospect  of  relief, 
whether  he  be  a  regular  or  an  irre'gular  practitioner. 

It  is  proper  to  add  that,  when  directing  this  diet, 
I  have  also  directed  that  every  possible  precaution 
should  be  taken  to  guard  against  fright.  Or  agitation  of 
mind,  of  any  kind ;  against  over-fatigue,  excessive  in- 
dulgence in  food,  and  all  other  exciting  causes.  I  will 
give  one  instance,  in  reference  to  this  point,  among 
several  which  I  have  known.  A  gentleman  brought 
me  his  son,  a  boy  of  about  twelve  years  of  age,  whose 
health  was  good  in  other  points^  but  in  whom  epilepsy 
occurred  under  its  most  certain  characters.  This  was 
in  February.  The  gentleman  lived  in  the  country, 
and  I  did  not  see  him  till  the  next  September.  He 
then  told  me  that  his  son  had  had  only  one  attack ;  and 
that  in  August,  after  an  excessive  indulgence  in  green 
apples.  The  apples  w^ere  subsequently  thrown  off. 
This  was  nearly  twenty  years  ago,  and  the  patient  has 
never  had  another  attack. 

In  cases  of  apoplectic  epilepsy  I  have  not  had  an 
opportunity  of  trying  the  diet  above  described.     In 


ON  EPILEPSY  AND   CONVULSION-FITS.  69 

one  I  believe  it  was  tried,  but  I  am  not  sure  how 
fully.  1  should  think  it  worthy  a  trial  in  such  cases, 
but  I  should  not  direct  it  with  much  confidence  of  suc- 
cess. In  suchj  as  in  all  the  other  cases,  a  careful 
attention  to  hygienic  rules  would  probably  be  of  some 
benefit. 

The  convulsive  Jits  of  children  bear  a  great  analogy 
to  those  of  epilepsy.  I  cannot  point  out  any  certain 
signs  by  which  they  may  be  distinguished  from  epi- 
lepsy, yet  they  do  not  seem  to  be  quite  the  same.  In 
most  instances  they  are  not  repeated ;  yet  in  some 
cases  they  are  repeated  often.  They  do  not  ordinarily 
continue  after  seven  years  of  age.  If  they  should  so 
continue,  I  think  the  fits  would  be  called  epileptic. 
As  in  epilepsy,  the  main  symptoms  are  spasms  and  a 
loss  of  consciousness.  These  fits  are  hereditary  in 
some  instances.  They  begin  in  the  early  periods  of 
infancy.  As  in  epilepsy,  a  paroxysm  may  be  induced 
by  various  exciting  causes.  The  fits  occur  during  the 
period  of  dentition,  and  are  sometimes  evidently  connected 
with  a  tooth  pressing  on  the  gums.  Errors  of  diet  are 
a  common  cause,  and,  when  the  powers  of  digestion  are 
impaired,  very  slight  errors  are  sufiicient.  These  fits 
occur  like  chills,  as  the  heralds  of  acute  disease. 
Thus,  in  a  boy  who  had  been  affected  during  dentition, 
subsequently,  a  fit  ushered  in  a  pneumonia.      After 


70  ON  EPILEPSY  AND   CONVULSION-FITS. 

this,  I  vaccinated  the  child,  and  then  said  to  the 
mother,  that  it  would  not  surprise  me  if  a  fit  should 
occur  at  the  time  of  the  constitutional  affection  from 
the  vaccination.  On  the  eighth  day  from  the  vaccina- 
tion the  fit  did  occur.  In  one  family,  now  living,  three 
children  have  been  the  subjects  of  these  fits.  They 
have  occurred  under  the  variety  of  circumstances  above 
described.  In  one  winter  each  in  succession  had 
bronchitis,  and,  a  few  weeks  afterwards,  each  had 
scarlatina.  At  the  commencement  of  each  of  these 
diseases  the  fits  occurred  in  every  one.  I  one  day 
said  to  the  mother,  I  suspect  that  you  or  your  husband 
may  have  had  this  disease  in  your  childhood.  She 
replied,  "  We  both  had  it." 

These  fits  cause  great  alarm  to  the  parents  and 
attendants,  and  violent  remedies  are  expected.  It  is 
important  to  understand  that  they  are  not  always 
needed.  If  the  stomach  be  full  when  they  occur,  or 
if  any  extra  food  has  been  taken,  or  if  there  be  nausea 
and  retching,  it  is  well  to  administer  an  emetic.  If 
there  is  costiveness,  an  injection  into  the  bowels  may 
be  the  first  remedy.  A  warm  bath  should  be  used 
early,  as  it  is  a  safe  remedy,  and  often  beneficial.  If 
the  fit  is  violent,  or  is  frequently  repeated,  and  the 
emetic  is  not  specially  indicated,  an  active  cathartic 
may  be  given.     I  think  this  will  commonly  be  found 


ON   EPILEPSY   AND    CONVULSION-EITS.  7l 

useful ;  for,  even  if  the  alimentary  canal  be  in  good 
order,  and  some  acute  disease  is  to  ensue,  this  remedy 
will  probably  be  beneficial.  Where  the  fits  continue 
in  a  vigorous  child,  where  the  pulse  is  firm,  more 
especially  if  the  face  be  flushed,  and  the  head  hot,  one 
or  two  leeches  may  be  used  with  advantage.  In 
obstinate  cases,  chloroform  is  said  to  have  been  useful. 
This  I  have  never  tried,  and  I  should  be  slow  to  do 
so.  If  employed  at  all,  it  should  be  with  extreme 
caution.  A  few  drops  may  be  sprinkled  on  a  hand- 
kerchief, and  this  may  be  held  near  the  nose. 

It  is  quite  important  that  the  parents  of  children 
subject  to  this  affection  should  be  apprised  that  violent 
remedies  are  not  always  to  be  employed.  It  is  not 
wonderful  that  the  parents  are  alarmed  in  such  cases ; 
but  the  real  hazard  is  very  slight.  It  is  true  that 
death  sometimes  follows  these  fits,  and  even  speedily ; 
but  I  presume  that  this  always  happens,  not  from  the 
fits,  any  more  than  it  would  from  chills,  but  from  the 
disease  on  which  the  fits  are  attendants.  In  such 
cases  the  real  disease  is  masked. 

Children  subject  to  these  fits  should  be  guarded 
against  all  the  exciting  causes.  But  for  this  purpose 
they  should  not  be  kept  in  a  nursery,  but  should  be 
invigorated  by  exercise  in  the  open  air,  and  be  inured, 
as  far  as  possible,  to  the  irritations  necessarily  attend- 


72  ON   EPILEPSY  AND   CONVULSION-FITS. 

ant  on  life,  though  protected  from  all  extraordinary 
causes  of  excitement.  Simplicity  and  regularity  in 
diet  should  be  rigorously  enforced.  The  hours  for 
sleep  should  be  regular,  and  they  should  go  to  their 
sleep  in  a  calm  state,  so  far  as  it  is  possible  to 
eflfect  it. 

Convulsion-fits  often  occur  in  the  disease  commonly 
known  under  the  name  of  acute  Hydrocephalus. 
Hence,  when  these  fits  occur  and  continue  with 
severity,  that  disease  is  apprehended.  I  believe,  how- 
ever, that  when  the  fits  occur  in  one  previously  in 
apparent  health,  and  prove  severe,  the  hydrocephalus 
rarely  follows. 

I  wish  also  to  say,  in  this  connection,  that  hydroceph- 
alus is  supposed  to  be  present  in  some  cases  where  the 
real  disease  is  typhoid  fever;  for  this  fever  is  not 
readily  distinguished  in  children,  especially  when 
there  is  great  stupor.  Yet  a  careful  examination  of 
the  whole  history  will  usually  remove  all  doubt.  In 
such  instances,  when  a  child  recovers,  undue  credit  is 
given  to  the  remedies  employed.  The  evil  of  this 
error  is  that  the  same  remedies  are  inflicted  upon  other 
children  without  benefit.  I  relieve  my  conscience  in 
stating  this.  Early  in  life  I  thought  I  had  saved  some 
children  under  hydrocephalus  by  shaving  the  head  and 
keeping  it  blistered.     In  one  instance  I  kept  the  blister 


ON   EPILEPSY   AND    CONVULSION-FITS.  73 

Open  for  many  days,  and  rejoiced  in  the  final  success 
of  the  remedy.  More  enlarged  experience  satisfied 
me  that  in  this,  and  other  such  cases,  the  real  disease 
was  typhoid  fever.  Further  than  this  I  have  not  any 
remark  to  make  on  this  hydrocephalus,  the  real  nature 
of  which  is'  much  betl«ir  uadtjrirtood  now  than  in  the 
early  part  of  this  century. 
7 


LETTEB.  V. 

ON   APOPLEXY   AND   PALSY. 

I  HAVE  a  little  to  say  about  apoplexy,  into  the 
description  of  which  I  shall  not  enter.  It  is  to  the 
treatment  I  wish  especially  to  call  your  attention. 
This  disease  is  very  commonly  spoken  of  as  belonging 
to  old  age,  and  as  occurring  mostly  in  persons  of  full 
habit,  with  large  heads  and  short  necks.  But  it  is 
also  seen,  and  not  very  rarely,  in  middle  age,  or  even 
earlier ;  also  it  occurs  in  persons  of  a  spare  habit, 
without  the  large  head  and  short  neck.  When  apo- 
plexy does  not  prove  fatal,  it  is  usually,  if  not  always, 
followed  by  palsy.  Palsy  occurs,  indeed,  without 
being  preceded  by  apoplexy.  In  many  instances 
there  is  a  very  slight  shock,  in  which  the  patient  loses 
his  consciousness  momentarily,  or  in  which  he  may  be 
said  to  be  confounded  for  a  moment ;  and  then  there 
will  follow  a  numbness,  or  loss  of  sensibility,  and 
more  or  less  diminution  of  the  power  of  voluntary 
motion.     These  last  are  the  si§;ns  of  palsy,  and  they 


OF  APOPLEXY  AND   PALSY.  75 

may  be  increased  to  any  degree,  rapidly  or  slowly, 
until,  perhaps,  there  is  an  entire  loss  of  sensibility, 
and  of  the  command  over  the  voluntary  muscles. 
Palsy  following  apoplexy  is  almost  invariably  limited 
to  one  side  of  the  body.  It  is  common  to  find  persons 
in  middle  life,  sometimes  under  forty,  sometimes  past 
fifty,  in  whom  one  of  the  slight  shocks,  which  have 
been  described,  is  followed  by  slight  palsy,  and  that 
not  very  lasting,  sometimes  not  continuing  more  than 
one  or  two  days.  The  patient  suddenly  falls  down, 
perhaps,  and  it  is  thought  he  may  be  faint  only.  He 
soon  rises,  and  does  not,  on  the  first  attack,  always 
show  any  palsy.  More  frequently,  one  of  the  extrem- 
ities is  affected,  or  the  muscles  of  the  face,  or  the 
organs  of  speech.  These  attacks  may  occur  at  various 
intervals,  of  from  a  few  months  to  two  or  three  years, 
and  at  last  prove  fatal ;  the  palsy  having  become  more 
severe,  perhaps,  after  each  apoplectic  attack.  I  call 
these  slight  attacks  apoplectic,  because  there  is  usually 
a  momentary  abolition  of  sense,  if  not  of  motion  :  and 
principally  because  I  have  reason  to  believe  that  they 
have  for  theii*  immediate  cause  an  effusion  of  blood, 
though  a  very  small  one,  within  the  cranium. 

I  have  given  this  brief  description  of  a  certain  class 
of  cases,  because  I  consider  them  more  susceptible  of 
relief  than  other  cases  of  apoplexy  and  palsy.     If 


76  ON   APOPLEXY  AND    PALSY. 

the  subject  of  these  attacks  is  of  a  constitution  to  bear 
it,  and  especially  if  the  symptoms  be  rather  more 
severe  than  I  have  described,  or  if  they  should  not  be 
lessening  within  twenty-four  hours,  venesection  is 
proper.  But,  in  these  cases,  there  is  not  so  much  risk 
at  the  moment,  as  there  is  of  their  recurrence  at  sub- 
sequent periods.  Hence,  the  great  object  in  the 
treatment  is  the  prevention  of  subsequent  attacks* 
I  should  have  made  my  remarks  on  apoplexy  and 
palsy  before  those  on  epilepsy,  had  I  not  wished  to 
state  first  the  results  of  my  experience  of  a  vegetable 
diet  in  this  latter  disease.  Influenced  by  my  experi- 
ence in  this,  I  have  been  led  to  the  same  treatment  in 
cases  such  as  I  have  described  above.  Besides  advising 
moderation  in  all  things,  I  have  directed  the  diet  just 
mentioned  to  be  continued  indefinitely.  If  one  says 
to  a  man  in  middle  life  that  he  should  never  eat  meat 
any  more,  he  may  rebel.  He  will  think  that  this  rule 
calls  for  more  self-denial  than  it  really  does.  It  is 
enough  to  suggest  abstinence  for  the  present,  and  at 
the  end  of  several  months,  or  pretty  certainly  in  a 
year,  most  men  become  more  indifferent  on  this  subject 
than  they  had  anticipated.  So  far  from  losing  muscu- 
lar power,  a  man  under  this  treatment  may  get  to 
endure  long-continued  labor,  and  to  make  as  great 
exertions  as  prudence  would  permit.     The  exercise  m 


ON  APOPLEXY  AND   PALSY.  77 

important,  and  should  be  a  part  of  his  treatment ;  but 
he  should  never  permit  himself  to  make  violent 
efforts.  He  should  also  be  enjoined,  as  far  as  possible, 
to  abstain  from  anger  and  anxiety.  And,  further,  when 
I  advise  abstinence  from  animal  food  for  an  indefinite 
period,  I  do  not  mean  to  say  that  this  abstinence 
should  continue  for  life.  I  know  not  what  length 
should  be  fixed  upon ;  but  this  appears  to  me  reason- 
able, that  the  patient  should  not  return  to  the  use  of 
animal  food  so  long  as  he  has  very  good  health  without 
it.  Whenever  it  appears  that  he  suffers  for  want  of 
such  food,  let  him  cautiously  resume  the  use  of  it. 

Take  a  brief  statement  of  two  cases,  in  which  this 
treatment  was  adopted;  in  both  of  which  there  had 
been  more  than  one  attack  within  twelve  or  eighteen 
months  before  a  strict  compliance  with  the  diet  pro- 
posed. One  gentleman  had  two  attacks,  so  slight 
that  their  nature  was  not  certainly  known.  In  twelve 
or  eighteen  months  from  the  first  he  had  a  third.  In 
this  the  paralytic  symptoms  were  unequivocal,  and 
continued  so  for  a  few  days.  The  right  hand  and  the 
speech  were  principally  affected.  He  did  not  entirely 
recover  the  use  of  his  hand ;  and  the  failure  in  speech, 
though  very  slight,  continued  for  a  long  time,  perhaps 
to  the  present  day.  The  last  attack  occurred  more 
than  five  years  since ;  but,  under  the  treatment  above 
7* 


78  ON  APOPLEXY  AND   PALSY. 

described,  there  has  been  no  recurrence  of  the  disease 
if  we  except  once  only,  when  there  was  a  ver^ 
transient  feeling,  reminding  him  of  the  former  attacks. 
The  other  instance  was  that  of  a  medical  friend 
whom  I  valued  very  highly.  His  first  attack  occurred 
in  April,  1845,  after  a  period  of  intense  professional 
labor,  and  the  day  after  making  a  difficult  and  tiresome 
dissection.  The  left  side  was  paralyzed,  not  very 
strongly ;  his  intellect  was  not  afiected  in  any  way. 
He  was  bled  at  this  time,  and  at  my  suggestion  he 
adopted  the  diet  which  I  have  mentioned.  At  the  end 
of  three  months  he  felt  perfectly  well,  and  relinquished 
the  diet.  In  March  of  the  following  year  he  had  a 
second  attack  of  paralysis,  in  which  the  right  side 
and  also  the  muscles  of  speech  and  deglutition  were 
afiected.  He  was  very  soon  well  enough  in  this,  as 
in  the  jjreceding  year,  to  return  to  his  business ;  but 
the  recovery  was  not  so  complete.  His  speech  was 
very  slightly  embarrassed,  and  the  motions  of  his  right 
hand  were  not  quite  perfect  for  two  or  three  years. 
Immediately  after  this  attack  he  began  the  vegetable 
diet  anew,  and  continued  it  until  his  death.  This 
took  place  from  accident  in  the  year  1853.  The 
recovery  progressed  regularly  soon  after  the  second 
attack,  and  during  the  last  four  years  of  his  life  hia 
health  and  vigor  were  as  good  as  they  had  ever  been. 


ON    APOPLEXY   AND    PALSY.  79 

* 

I  hope  that  you  will  not  understand  me  tc  say  that 
ihis  treatment  will  always  be  successful.  But  I  feel 
assured,  first,  that  it  is  safe.  Therein  it  differs  from 
any  active  medical  treatment;  and  I  say,  moreover, 
that  it  offers  a  better  chance  for  permanent  relief  and 
a  restoration  to  useful  health,  than  any  other  mode  of 
treatment  with  which  I  am  acquainted. 

I  must  make  a  few  remarks  on  the  facial  paralysis , 
the  full  history  and  explanation  of  which  would  be 
enough  to  immortalize  Sir  Charles  Bell,  if  he  had 
done  nothing  more.  You  are  aware  that  this  disease  is 
traced  to  an  interruption  of  the  nervous  influence  in  the 
facial  nerve.  First,  I  will  remark  that  it  is  often  pre- 
ceded or  accompanied  by  a  pain  in  the  ear ;  and  once  I 
saw  it  preceded  by  hemicrania  for  two  or  three  days.  In 
such  cases,  as  soon  as  the  paralysis  shows  itself  with 
its  peculiar  character,  the  nature  of  the  disease  must 
be  obvious.  When  there  is  pain  in  the  ear,  it  is 
advisable  to  commence  the  treatment  with  a  good 
leeching,  or  cupping.  I  say  this  pointedly,  because 
in  such  cases  there  is  hazard  that  the  whole  auditory 
nerve  may  be  involved  in  an  inflammation.  Should 
this  happen,  deafness  may  follow,  as  well  as  a  paraly- 
sis of  the  face.  But  in  most  cases  of  the  disease,  1 
believe  a  recovery  would  be  spontaneous,  without 
treatment.     Yet,  if  the  patient  is  in  good  vigor,  it 


80  ON   APOPLEXY   AND   PALSY. 

will  be  well  to  use  leeches  and  a  blister  behind  the 
ear. 

I  have  mentioned  this  disease  mostly  to  introduce 
two  cases.  A  physician  once  called  on  me  with  a 
facial  paralysis.  He  was  of  a  full  habit,  and  his  face 
was  always  very  red,  though  a  tee-totaller.  His 
father  had  died  of  apoplexy,  and  he  had  had  a  brother 
and  a  sister  affected  with  hemiplegia.  It  is  not 
strange  that  this  patient  believed  himself  to  be  threat- 
ened with  this  family  disease.  In  truth,  he  was  not 
acquainted  with  the  characteristics  of  this  variety 
of  palsy.  He  was  desponding.  I  could  not  deny 
that,  in  his  case,  any  symptom  of  paralysis  was  a 
proper  cause  for  alarm ;  but,  on  the  strictest  exami- 
nation, I  could  not  discover  any  affection  of  the 
mind,  nor  diminution  of  the  sensibility  in  any  part  of 
the  body  ;  and  the  palsy  on  one  side  of  the  face  showed 
itself  only  when  the  muscles  of  the  face  were  called 
into  action,  and  in  the  inability  to  close  the  eyelids. 
This  in  some  measure  was  a  test  case  ;  a  test  as  to  the 
confidence  with  which  the  diagnosis  and  prognosis 
might  be  declared.  I  ventured  to  assure  the  patient 
of  his  safety,  and  that  he  would  probably  recover  in  a 
short  time.  He  could  hardly  place  faith  in  me,  but 
the  result  was  entirely  favorable ;  and  now,  at  the  end 
of  twenty  years,  he  is  in  good  health.     This  case 


ON  APOPLEXY   AND   PALSY.  81 

shows  that  we  may  place  great  reliance  on  the  peculiar 
symptoms  of  this  kind  of  palsy  ;  and  that  it  is  quite  a 
different  affection,  as  regards  its  seat,  from  the  palsy 
following  apoplexy. 

I  shall  state  another  case,  to  show  that  it  is  not 
always  safe  to  promise  a  recovery  from  this  disease. 
I  have  seen  more  than  once  instance  in  which  the 
disease  proved  lasting.  In  the  one  I  refer  to,  the 
disease  had  existed  for  many  months  before  I  saw  it. 
The  palsy  had  diminished,  but  had  not  disappeared. 
There  was  frequent  pain  in  the  head,  and  occasionally 
this  became  severe.  Yet  in  most  respects  the  health 
was  very  good.  It  appeared  that,  at  some  time  not 
long  preceding  the  paralysis,  the  patient  had  received 
a  violent  blow  on  the  forehead.  Under  these  cir- 
cumstances, I  apprehended  some  organic  change 
within  the  cranium.  The  patient  was  benefited  by  a 
vegetable  diet.  While  he  pursued  this,  and  restrained 
himself  to  a  very  moderate  quantity  of  food,  every- 
thing did  well,  except  only  the  remnant  of  the  paraly- 
sis. He  was  convinced  of  the  benefit  of  this  course, 
but  he  declared  to  me  that  his  hunger  was  so  great 
that  he  could  not  endure  the  abstinence.  At  length, 
after  a  new  indulgence,  stupor  came  on,  and  under 
this  he  died  in  three  or  four  days.  On  examination, 
there  was  found  a  tumor  in  the  anterior  lobe  of  th© 


82  ON  APOPLEXY   AND   PALSY. 

cerebrum,  on  the  side  aifected.  Here  there  was  a 
complication,  manifested  by  the  severe  pain  in  the 
head,  at  intervals,  and  by  the  undue  prolongation  of 
the  palsy. 

There  is  a  palsy  produced  by  lead.  In  some  cases 
I  have  found  it  is  sufficient  that  the  patient  should 
no  longer  use  the  water,  or  meddle  with  any  other 
material,  in  which  lead  was  contained.  I  deem  it 
important  to  state  this,  as  showing  that  active  and 
powerful  treatment  need  not  be  adopted  in  mild  cases. 
But,  in  cases  where  the  paralytic  symptoms  are 
strong,  I  feel  no  doubt  of  the  advantages  which  may 
be  obtained  from  the  use  of  strychnine.  On  this  sub- 
ject I  will  refer  you  to  a  report  drawn  up  by  my 
friend.  Dr.  Horatio  Adams,  of  Waltham,  and  pub- 
lished in  the  fifth  volume  of  the  Transactions  of  the 
American  Medical  Association.  I  will  here  add,  in 
respect  to  all  cases  of  disease  produced  by  lead,  that  I 
believe  the  hydriodate  of  potass  may  be  used  with 
decided  benefit.  See,  on  this  subject,  the  British  and 
Foreign  Medico-Chirurgical  Review,  Nos.  21  and  22, 
for  January  and  April,  1853. 

Before  leaving  this  subject  of  palsy,  I  wish  to  refer 
to  an  affection,  which,  I  think,  may  be  called  mimotica, 
or  mimicking  palsy.  Patients  now  and  then  present 
themselves   having   symptoms    resembling   those   of 


ON   APOPLEXY   AND   PALSY.  83 

paralysis,  and  exciting  their  apprehensions  therefore. 
Such  persons  do  not,  ordinarily,  manifest  any  agita* 
tion  of  mind ;  on  the  contrary,  they  preserve  a  calm 
demeanor.  At  first  view,  one  must  partake  of  these 
apprehensions,  which,  however,  will  commonly  be  re- 
moved in  a  few  days,  if  not  on  the  first  examination. 
First  of  all,  the  symptoms  are  what  are  called  sub- 
jective, and  not  objective.  There  is  a  numbness  in 
various  parts,  shifting  from  place  to  place,  and  seen 
manifesting  itself  in  many  parts  at  the  same  time. 
This  is  attended  with  a  feeling  of  stiffness  in  the 
fingers,  or  elsewhere.  The  patient  will  move  his 
fingers  very  well,  so  far  as  you  see ;  but  he  feels  a 
difficulty  in  doing  it.  Sometimes  there  is  also  a  pain 
in  the  course  of  the  spine,  or  some  unusual  feeling 
about  the  head.  These  symptoms  do  not  come  on 
suddenly,  as  from  a  stroke  on  the  head ;  on  the  con- 
trary, they  crawl  on  gradually,  and  the  patient  cannot 
well  tell  when  they  began.  There  is  likewise  a  want 
of  steadiness  in  the  symptoms ;  they  consist  in  the 
feelings  of  the  patient,  and  those  feelings  are  shadowy. 
The  patient  speaks  on  the  subject  with  calmness  ;  but 
usually  there  may  be  discovered  a  dejection  of  spirits, 
and  an  anxiety.  If  these  can  be  removed,  the  symp- 
toms are  alleviated.  Yet  it  is  not  to  be  understood 
that  the  feelings  are  imaginary;    they  really  exist. 


84  ON  APOPLEXY   AND   PALSY. 

The  important  thing  in  the  case  is  that  the  physician 
should  feel  assured  as  to  his  diagnosis.  To  do  this,  he  ^ 
must  make  a  careful  inquiry,  and  it  is  better  that  he 
should  not  hurry  to  a  decision.  Then,  if  he  does  de- 
cide that  the  case  comes  under  the  above  description, 
the  patient  will  place  confidence  in  his  decision,  and 
be  encouraged  by  it.  I  once  had  a  case  where  the 
father  of  the  patient  had  had  apoplexy,  followed  by 
hemiplegia.  Of  course,  I  felt  some  doubt  in  this 
instance ;  but,  after  examining  the  patient  twice  with 
great  care,  I  became  decided  in  my  opinion  ;  and,  by 
communicating  my  confidence  to  the  patient,  his  mind 
was  soon  relieved.  This  occurred  several  years  since, 
and  the  patient  is  now  in  very  good  health.  In  this 
instance  the  patient  had  been  exhausted  by  labor  and 
anxiety ;  labor  of  mind,,  and  not  of  body,  and  without 
due  exercise  abroad.  The  same  is  true  in  most  in- 
stances ;  or,  if  not  just  so,  there  has  been  some  cause 
operating  to  exhaust  the  powers,  and  usually  such  as 
to  waste  the  flesh  before  the  attack.  Relief  is  to  be 
found  by  rest  from  mental  labor,  relief  from  anxiety, 
amusement,  change  of  place,  as  in  travelling,  tonics 
and  stimulants.  It  is  one  of  the  affections  of  the 
nervous  system  in  which  wine  affords  great  relief. 
It  is  only  necessary  that  the  use  of  it  should  be  regu- 
lated with  discretion. 


LETTER    YI.  • 

ON    CHOREA,    NEURALGIA   AND    PAIN. 

Chorea  is  one  of  the  nervous  diseases.  I  shall  not 
describe  it ;  but  I  have  something  to  offer  upon  its 
treatment.  In  a  nosological  system  this  would  have 
been  brought  into  connection  with  epilepsy.  This  dis- 
ease usually  occurs  in  young  persons ;  and,  with  rare 
exceptions,  terminates  spontaneously  in  from  two  to 
four  months. .  It  often  occurs  during  the  period  of  the 
second  dentition,  and  sometimes  shows  itself  the  second 
or  third  time,  at  about  the  same  season  of  the  year. 
It  is  said  to  be  chronic  in  some  instances,  and  I  have 
seen  cases  which  were  so  regarded.  But  I  feel  as- 
sured that  they  were  different  in  their  nature.  In  the 
treatment  of  it  various  tonics  are  employed  with  suc- 
cess. Iron,  especially  the  carbonate  of  iron,  in  large 
doses,  also  the  shower-bath,  have  removed  the  disease 
in  a  very  short  time.  I  have  seen  the  valerianate  of 
zinc  useful,  where  other  remedies  failed,  and  w^here 
the  patient  could  not  take  the  oil  of  turpentine.  This, 
8 


86  ON   CHOREA,    NEURALGIA   AND    PAIN. 

"was  in  a  young  lady  past  eighteen.  But  the  great 
remedy  is  the  oil  of  turpentine.  As  it  is  not  an 
agreeable  one,  if  the  case  be  mild,  other  remedies  may 
be  tried  first.  In  a  severe  case,  however,  or  where 
other  remedies  fail,  this  should  be  used.  -The  oil 
should  be  given  in  such  doses  as  the  patient  can  bear. 
In  a  very  young  child  you  may  begin  with  five  drops 
three  times  a  day ;  but  the  dose  should  be  increased 
steadily  until  relief  is  obtained,  if  no  objection  occurs 
The  objections  are,  first,  nausea;  but  this  is  not  com- 
mon ;  second,  too  great  an  operation  on  the  bowels ; 
and  third,  and  chiefly,  irritation  of  the  urinary  organs. 
If  employed  too  freely,  it  will  produce  bloody  urine 
and  great  distress.  If  the  attendants  are  aware  of 
these  difficulties,  and  watch  for  them,  no  serious  incon- 
venience need  ensue.  A  child  of  eight  or  ten  years 
of  age  will  sometimes  bear  a  teaspoonful  for  a  dose. 
This  remedy  is  successful,  whether  given  early  or  late 
in  the  disease. 

I  will  only  add,  that  I  never  saw  an  instance  in 
which  chorea  proved  fatal,  except  once.  The  patient 
was,  I  think,  twenty  years  of.  age,  and  in  full  health 
previous  to  the  occurrence  of  the  disease.  The  spas- 
modic afiection  was  very  severe  and  very  constant.  I 
saw  her  only  a  day  or  two  before  her  death,  under  the 
care  of  a  judicious  and  learned  physician,  in  whose 


NEURALGIA   AND    PAIN.  87 

treatment  of  the  case  I  saw  no  fault.     Unfortunately, 
no  autopsy  was  permitted. 

At  the  present  day  we  hear  much  of  a  disease 
called  Neuralgia.  This  name  is  applied  to  any  case 
of  severe  pain  which  cannot  be  traced  to  inflammation, 
nor  to  any  organic  affection.  I  have  sometimes  ven- 
tured to  laugh  on  this  subject,  saying  that  the  patient 
informs  the  physician  that  she  is  frequently  troubled 
with  a  severe  pain,  without  any  other  symptom  of  dis- 
ease ;  and  she  asks  what  is  its  nature,  and  what  is  its 
cause.  She  says  it  is  pain,  in  plain  English,  and  he 
answers  her  in  Greek,  that  it  is  a  neuralgia.  It  is,  no 
doubt,  a  satisfaction  to  her  to  know  that  her  disease 
has  a  distinct  name.  I  rather  prefer,  however,  to 
reply  that  it  is  a  pain,  and  that  that  is  all  we  know 
about  it.  I  say  this  the  more  because  there  is  an 
affection  properly  named  neuralgia.  Sauvages,  the 
father  of  nosology,  admitted  in  his  system  an  order 
named  Dolores.  That  was  not  plain  English,  but  it 
was  plain  Latin,  and  gave  a  name  to  the  diseases 
which  consist  in  pain  only ;  or  in  pain  only,  so  far  as 
we  know.  Now  we  know  that,  when  pain  exists  any- 
where, as  we  know  with  regard  to  every  sensation, 
it  is  transmitted  through  the  nerves  to  the  brain 
and  to  the  mind ;  but  we  do  not  say  that  the  nerve 
is  diseased,  or  that  the  disease  is  situated  in  the  nerve 


88 


m  every,  case  where  pain  occurs.  But  there  is  a  dis- 
ease where  the  pain  appertains  to  the  nerves  them- 
selves^ and  this  is  shown  by  its  limitation  to  the 
ramifications  of  some  one  nerve,  or  branch  of  a  nerve. 
Thus,  when  there  is  a  pain  passing  from  directly 
below  the  eye,  and  spreading  over  the  cheek,  no  other 
symptom  coexisting,  we  perceive  that  this  belongs  to 
the  infra-orbital  branch  of  the  fifth  pair  of  nerves.  Or, 
when  a  pain  is  passing  in  the  neighborhood  of  the 
great  trochanter,  following  the  course  of  the  great 
sciatic  nerve,  and  dividing  as  that  nerve  branches  upon 
the  leg,  we  consider  it  a  disease  of  that  nerve.  It  is 
a  painful  affection,  appertaining  to  the  nerve  itself; 
being  a  disease  in  the  nerve.  If  we  have  a  pain 
seated  in  the  epigastrium,  limited  to  a  small  space,  it 
may,  perhaps,  be  an  affection  of  a  nerve  in  that  situa- 
tion ;  but  we  have  no  evidence  that  it  is  so,  and  it  is 
an  assumption  to  call  it  a  neuralgia.  We  do  not  find 
it  following  the  ramifications  of  any  large  nerve.  I 
do  not  here  wish  to  quarrel  about  words,  but  it  ap- 
pears to  me  that  there  is  a  real  distinction  between 
the  things  themselves,  and  therefore  they  should  be 
called  by  different  names.  When  this  is  not  done,  the 
physician,  who  has  been  able  to  give  relief  to  a  severe 
pain  in  any  part,  urges  the  trial  of  his  remedy  in 
oases   of  proper  neuralgia;    but    the    patient,   who 


89 


employs  the  twenty  successful  remedies  recommended 
by  as  many  different  physicians,  is  wearied,  and,  per- 
haps, injured,  and  the  profession  is  discredited. 

The  true  neuralgia  is  very  irregular,  ceasing  for  a 
long  while,  and  then  recurring;  or  at  other  periods 
felt  every  day,  and  almost  every  hour ;  but  the  disease 
is  very  rarely  permanently  overcome  by  remedies. 
This  is  not  true  in  regard  to  other  cases  of  severe  pain, 
where  it  is  pain  alone.  The  disease  in  these  cases  is 
often  very  obstinate,  and  resists  the  influence  of  power- 
ful remedies ;  but,  most  commonly,  temporary  relief 
can  be  obtained  from  narcotics  and  anaesthetics ;  and 
often  permanent  relief  from  quinia  and  iron.  Among 
the  narcotics,  opium  is,  perhaps,  the  most  certain; 
but  its  subsequent  effects  make  the  use  of  it  very 
inconvenient,  and  often  very  deleterious.  If  other 
narcotics  can  answer  the  purpose,  even  less  perfectly, 
they  are  to  be  preferred.  Of  these,  the  most  power- 
ful which  I  have  employed  internally  is  stramonium. 
We  have  a  guide  in  the  use  of  this  in  its  effects  upon 
the  vision.  When  this  is  impaired  the  dose  must  not 
be  increased,  nor  the  medicine  repeated,  until  the 
blindness  has  subsided. 

For  permanent  relief  I  believe  that  quinia  may  be 
relied  upon  more  than  iron.  To  be  effectual  the  qui- 
nia should  be  given  in  as  large  doses  as  the  patient 
8* 


90  ON  CHOREAj    NEURALGIA  AND   PAIN. 

can  bear,  as  is  done  when  it  is  given  for  intermittent 
fever.  It  does  not  appear  that  the  benefit  depends 
upon  the  tonic  power  of  the  quinia.  The  good  effect 
of  this  article  in  arresting  the  progress  of  intermittent 
fever  is  not  in  proportion  to  any  tonic  effect.  It  would 
seem  rather  to  depend  on  a  power  to  lessen  or  remove 
the  susceptibility  to  disease.  Now,  I  have  thought 
that  the  quinia  acts  in  the  same  way  in  other  diseases, 
even  when  not  intermittent.  I  shall  have  occasion,  in 
subsequent  letters,  to  point  out  instances  in  which  this 
power  is  manifested.  Probably  arsenic  operates  in  the 
same  way. 

Narcotics  applied  externally  have  often  a  good  effect 
in  cases  of  simple  pain.  Among  these  I  give  a  pref- 
erence to  aconite.  I  use  the  saturated  tincture,  which 
is  a  cheap  article  compared  with  any  of  the  alkaloids. 
Some  care  is  necessary  in  the  use  of  this  article.  It 
should  be  rubbed  on  the  part  in  pain,  or  as  near  to  it 
as  may  be.  If  the  nurse  who  applies  it  gets  any  upon 
her  finger,  and  then  touches  her  eye,  great  pain  ensues, 
and  sometimes  the  eye  becomes  inflamed.  It  is,  there- 
fore, proper  to  direct  that  a  basin  of  water  be  placed 
close  at  hand  before  beginning  the  application;  by 
this  the  nurse  will  be  reminded  to  wash  her  hand  as 
soon  as  the  rubbing  is  finished.  The  trial  of  this 
article  is  most  satisfactory  when   some   stinging    or 


NEURALGIA   AND    PAIN.  91 

smarting  is  experienced  during  the  rubbing.  Usu- 
ally some  numbness  in  the  part  follows  the  appli- 
cation, and  occasionally  this  numbness  continues  a 
long  time. 


LETTER  VII. 

ON    SOMNAMBULISM,   ANIMAL    MAGNETISM,   AND    IN- 
SANITY. 

As  I  have  formerly  said,  there  are  diseases  of  the 
nervous  system  which  cannot  be  explained;  for  we 
cannot  explain  the  mode,  in  which  the  common,  or  nor- 
mal operations  of  this  system  take  place.  At  the 
present  day  no  one  would  undertake  to  show  what  is 
the  difference,  as  to  the  state  of  the  brain  and  nerves, 
in  sleeping  and  watching ;  but  thus  much,  I  believe, 
may  be  safely  asserted,  that  the  whole  of  the  nervous 
system  is  not  uniformly  affected  in  an  equal  degree 
during  sleep.  Sometimes  the  senses,  the  mind,  and 
the  muscles  of  locomotion,  all  equally  sleep ;  this  is 
sound  and  perfect  sleep.  But,  more  commonly,  sleep 
does  not  take  place  equally  in  all  those  parts ;  and, 
especially,  the  mind  is  often  in  an  active  state  while 
the  senses  and  the  muscles  sleep.  This  is  called 
dreaming.  Then  a  man  keeps  quietly  in  his  bed; 
and,  as  dreaming  is  a  common  occurrence,  it  excites 


ON   SOMNAMBULISM,    ETC.  93 

no  wonder.  But,  as  it  is  less  common,  it  excites  more 
attention  when  you  hear  of  one  who  frequently  rises 
from  his  bed  in  the  night  and  walks  about.  Such  a; 
person  is  called  a  sleep-walker,  or  somnambulist. 
Some  somnambulists  engage  in  the  business  and  labors 
which  belong  to  their  waking  hours.  A  woman  sets 
her  breakfast-table ;  a  man  goes  into  the  field  and 
hoes  his  corn;  and  sometimes  the  student  occupies 
himself  in  writing.  Here  it  seems  difficult,  at  first 
view,  to  distinguish  between  sleeping  and  waking. 
Yet,  ordinarily,  there  is  something  in  the  conduct  of 
these  persons,  by  which  it  is  obvious  that  they  are  not 
in  the  natural  waking  state.  In  general,  they  do  not 
talk,  and  do  not  seem  to  hear  one  speaking  to  them  in 
common  tones.  If  roused  by  violence,  they  show  sur- 
prise and  confusion  of  mind.  If  left  to  themselves, 
these  persons  usually  return  to  their  beds,  and  the 
next  day  are  not  at  all  aware  of  what  has  occurred 
during  the  night.  I  say  during  the  night,  for  I  do  not 
recollect  any  instance  of  a  person,  falling  asleep  during 
the  day,  having  been  afiected  by  ordinary  somnambu- 
lism. 

I  have  made  rather  a  long  preface  to  an  interesting 
case,  which  I  wish  to  relate  to  you.  I  will  not  say 
that  it  is  one  of  any  great  practical  value,  but  it  may 
throw  some  light  upon  phenomena,  which  fall  under 


94: 


common  oDservatioiij  and  may  prevent  too  much 
apprehension,  if  a  similar  case  should  ever  come 
under  your  own  care. 

The  case  I  refer  to  was  that  of  Miss  S ,  about 

eighteen  "years  of  age,  who  was  under  my  care  more 
than  forty  years  ago.  She  was  a  visitor  in  the  town, 
at  the  house  of  an  aunt,  and,  though  her  family  was 
well  known  to  me,  I  was  not  then  acquainted  with 
their  constitutions.  I  will  say  now,  what  I  learned 
subsequently,  that  they  were  all  very  liable  to  nervous 
diseases,  and  especially  to  affections  of  the  brain. 
This  young  lady,  very  soon  after  I  saw  her,  and  I  be- 
lieve on  the  first  day,  was  singularly  affected  in  the 
early  part  of  the  evening.  It  was  said  that  she  had 
fallen  asleep  and  then  roused  to  the  state  in  which  I 
saw  her.  In  her  ordinary  state  she  was  extremely 
modest  and  bashful.  Now,  I  found  her  with  her  eyes 
widely  opened,  instead  of  being  downcast,  and  with 
an  air  of  boldness.  She  appeared  to  be  in  some  dis- 
tress, and  referred  to  the  epigastrium  as  the  seat  of 
her  trouble.  At  some  moments  she  appeared  to  have 
extreme  pain  there.  She  was  not  tranquil  at  any 
time,  but  occasionally  the  muscles  of  her  limbs  and 
those  of  the  abdomen  became  rigid.  Those  of  the 
face  were  affected  in  like  manner,  and,  being  accom- 
panied by  staring,  she  had  an  expression  of  sternness. 


95 


But  these  tonic  spasms  were  transient,  and  most  of 
the  time  she  was  at  rest.  She  talked  freelj,  as  if 
awake,  but  in  a  manner  totally  different  from  her 
own  when  in  a  waking  state.  She  had  a  certain  set  of 
notions,  and  all  which  she  said  conformed  to  them ; 
but  these  notions,  as  well  as  her  manner,  were  totally 
different  from  anything  shown  in  her  normal  state. 
With  all  this  there  was  not  any  remarkable  change  in 
the  organic  system.  She  had  nothing  which  you  could 
call  fever.  She  did  not  take  much  nourishment,  but 
she  took  enough  to  support  her.  The  paroxysm  under 
which  I  saw  her  subsided  after  a  few  hours,  when 
she  had  a  natural  sleep ;  and  the  next  morning  she 
appeared  very  well,  although  enfeebled.  A  paroxysm 
of  the  same  general  character  occurred  every  evening 
for  about  three  weeks.  In  these  paroxysms  she  remem- 
bered very  well  what  had  passed  in  the  preceding 
ones;  but  in  her  normal  state  she  could  not  recall 
anything,  which  had  taken  place  in  the  morbid  state 
In  the  morbid  state  she  addressed  those  about  her  as 
knowing  them,  but  to  three  or  four  persons  whom  she 
saw  the  most,  she  gave  false  names,  and  uniformly 
recognized  them  under  the  same  names;  but  they 
were  the  names  of  real  persons.  To  her  aunt  she 
gave  the  name  of  an  old  nurse  whom  she  had  known ; 
and  she  called  me  by  the  name,  of  one  of  her  brothers, 


96  ON   SOMNAMBULISM,    ETC. 

considering  me  as  being  her  brother.  She  objected  to 
my  leaving  her,  and  made  me  promise  to  see  her  early 
the  next  evening.  The  next  evening,  if  I  did  not 
enter  until  the  paroxysm  had  commenced,  she  would 
reproach  me  for  being  tardy.  I  saw  her  several  even- 
ings before  the  paroxysm,  and  noted  the  manner  of  its 
occurrence.  While  lying  quietly  on  her  bed  she 
would  undergo  a  sudden  change.  She  would  start, 
and  her  countenance  would  become  distorted.  Her 
eyes  would  be  opened  widely,  and  she  would  strike 
her  hand  upon  the  epigastrium,  appearing  to  be  in 
great  agony.  With  this,  or  shortly  after,  some  spasms 
would  take  place,  more  or  less  extensive.  For  a  time 
her  jaws  would  be  set,  and  she  would  utter  no  articu- 
late sound,  though  her  groans  would  indicate  suffering. 
It  soothed  her  if  I  removed  her  hands,  and  pressed 
my  own  on  the  epigastrium ;  and  the  more,  if  I  did  so 
with  all  the  strength  I  possessed.  In  a  longer  or 
shorter  time  she  would  become  calm,  and  then  I  would 
commonly  have  a  very  pleasant  conversation  with  her. 
She  never  lost  her  own  identity,  but  I  believe  she  did 
not  know  where  she  was,  and  showed  no  curiosity  with 
respect  to  her  situation.  On  some  occasions  she  mani- 
fested violent  emotions,  and  on  one  evening  particu- 
larly, jumping  from  her  bed,  she  climbed  up  the  bed- 
post like  a  kitten,  and  afterwards  made  an  attempt  to 


97 


jump  out  of  the  window.  In  this  she  was  quite  in 
earnest,  and  it  required  one  person  in  addition  to 
myself  to  prevent  her  from  accomplishing  her  pur- 
pose. The  most  remarkable  thing  was  the  double 
consciousness ;  for,  though  she  never  considered  her- 
self as  a  diiferent  person  in  the  morbid  state,  yet  she 
was  of  a  totally  different  character  ;  and  in  that  state 
she  could  not  be  made  to  remember  what  had  occurred 
in  the  preceding  day,  as  in  the  sound  state  she  did  not 
remember  the  occurrences  of  the  night.  Yet,  in  each 
state  she  recalled  all  which  had  taken  place  in  the 
same  state,  during  the  period  of  her  sickness.  Her 
memory  seemed  to  have  two  distinct  store-houses ; 
one  for  the  normal  and  one  for  the  morbid  state. 

The  disease  was  a  new  one  to  me,  as  it  was  also  to 
the  older  practitioners  who  were  called  to  consult  with 
me.  Remedies  were  tried,  corresponding  to  the  differ- 
ent notions  suggested  as  to  the  nature  of  the  difficulty, 
but  without  any  benefit.  I  very  soon  became  satisfied 
that  medicine  was  not  of  any  use  to  her,  and  aimed 
only  to  avoid  everything  which  should  aggravate  the 
trouble.  The  disease  subsided  gradually,  but  left  her 
much  enfeebled. 

I  learned  that  several  months  before  I  saw  her,  she 
had  undergone  a  similar  course  of  disease,  in  another 
town,  not  at  her  own  home.  At  that  time,  the  sick- 
9 


98 


ness  had  been  shorter,  and  I  believe  not  quite  so  reg- 
ular in  its  course.  She  lived  many  years  after  the 
disease  which  I  have  described,  and  always  exhibited 
marks  of  a  nervous  temperament ;  but  she  never  again 
was  aJBfected  with  double  consciousness.  She  was  mar- 
ried, and  then  lived  in  this  city.  After  several  years 
she  became  pregnant.  She  had  not  quite  reached  her 
term  when  labor  took  place,  and  she  gave  birth  to  a 
dead  child.  Severe  convulsions  ensued,  under  which 
she  died.  It  happened  at  a  time  when  I  was  absent 
from  the  city,  so  that  I  am  not  able  to  state  the  par- 
ticulars minutely.  I  ought  to  say,  respecting  this 
patient,  that  she  was  an  amiable  and  intelligent 
woman ;  not  at  all  whimsical,  nor  irregular  as  to  her 
conduct ;  on  the  contrary,  quite  discreet. 

A  knowledge  of  this  case,  and  of  others  similar 
which  the  books  furnish  us,  has  helped  me  in  form- 
ing opinions  on  the  subject  of  animal  magnetism.  It 
shows  that  the  human  mind  can  pass  from  a  natural 
to  a  morbid  or  unnatural  state  very  suddenly ;  and 
that,  under  its  change,  it  may  temporarily  view  sub- 
jects in  a  new  light,  and  be  affected  in  a  manner  quite 
different  from  that  which  is  common  to  it.  When  I 
first  saw  persons  in  the  magnetized  state,  as  it  is 
termed,  I  was  struck  with  the  resemblance  of  their 
cases  to  that  of  my  interesting  patient.     I  examined 


ETC.  99 

several  persons  in  this  magnetic  state.  All,  whom  I 
saw,  were  females,  and  I  believe  all  fairly  ranked  in 
the  class  of  nervous  people. 

The  doctrine  commonly  received  is  this :  that  one 
person  is  capable  of  throwing  another  into  the  mag- 
netic state  by  some  influence,  which  he  exercises  over 
the  subject.  But  it  is  notorious  that  the  magnetizer 
cannot  succeed  with  all  persons  ;  and,  indeed,  only  on 
a  small  proportion  of  persons.  Now,  I  believe  the 
true  doctrine  is  this  :  that  there  are  some  persons  who 
can  go  into  the  magnetized  or  somnambular  state,  and, 
yielding  themselves  up  to  the  operator,  they  fall  into 
this  state.  It  is  not  that  the  magnetizer  possesses  any 
peculiar  power ;  but  that  the  magnetizee^  if  I  may 
coin  a  word  for  the  occasion,  is  liable  to  be  affected  in 
a  peculiar  way,  and  becomes  so  affected,  whenever  so- 
licited by  one  professing  to  possess  a  peculiar  power 
or  faculty.  There  is  not  any  trick  about  this.  The 
magnetizee  is  really  brought  into  a  state  different  from 
the  normal  state.  This  state  is  exceedingly  like,  if  it 
is  not  identically  the  same,  as  regards  its  essential 
characters,  as  that  of  my  patient  under  double  con- 
sciousness.    We  had  had  no  experience  of  this  animal 

magnetism  when  I  attended  Miss  S ,  whose  case  I 

cave  described ;  but,  at  that  time,  I  began  to  think 
Uiat  I  had  some  influence  in  producing  the  nightly 


100  ON   SOMNAMBULISM,    ETC. 

return  of  the  morbid  state  ;  because  this  usually  took 
place  soon  after  my  entrance  into  the  patient's  room  i 
so  thatj  at  last,  I  ceased  my  regular  attendance  in  the 
evening,  and,  as  I  suspected,  with  benefit  to  the 
patient,  although  the  change  was  not  effected  imme- 
diately. At  the  time  that  Miss  Brackett  was  distin- 
guished as  a  magnetizee  in  Providence,  and  when 
there  were  two  other  young  ladies  there  distinguished 
in  the  same  way,  I  visited  that  place  for  the  purpose 
of  seeing  them.  Having  these  notions  in  my  mind,  I 
asked  Miss  Brackett  if  she  had  ever  been  subject  to 
somnambulism.  She  answered  that  she  had  not  been, 
but  that  she  had  a  brother  who  had  been  a  very  re- 
markable somnambulist.  He  had  hoed  his  corn  in  the 
ndght,  aiwi  done  various  other  things,  such  as  are  not 
often  met  with.  This  corresponded  with  my  opinion^ 
previously  entertained,  that  th^re  was  a  tendency  in 
the  constitution  of  the  subject  to  somnambulism.  In 
this  connection  it  should  be  remembered  that  the  first 
change  cardinarily  produced  in  this  process  c£  animal 
magnetism,  so  called,  is  to  put  the  subject  asleep. 
There  she  remains  unless  the  magnetizer  uses  his 
influence  to  produce  a  partial  wakening.  This  waken- 
ing is  an  exhibition  of  the  double  consciousness.  In 
Miss  Brackett' s  case  I  found  that,  when  in  this  abnor- 
mal state,  she  remembered  what  had  befallen  he? 


ON  SOMNAMBULISM,    ETC.  101 

when  in  the  same  state  at  a  previous  time.  During 
the  magnetic  sleep  the  subject  continues  to  feel  a 
dependence  on  the  magnetizer,  so  as  to  awake  when- 
ever he  makes  known  to  her  his  wish  that  she  should 
wake.  It  has  been  said,  indeed,  that  the  magnetizer 
can  exercise  an  influence  to  make  the  subject  sleep,  or 
wake,  without  making  his  wishes  known  to  her  by  any 
sign.  This  I  doubt.  I  have  witnessed  efforts  of  this 
kind ;  but,  upon  close  watching,  it  was  plain  that  no 
effect  was  produced  until  the  subject  was  apprized  of 
the  design  of  the  magnetizer.  And  in  cases  related  to 
me  by  others,  I  never  found  one  where  it  was  proved 
that  the  magnetizee  was  influenced  without  any  sign 
from  the  magnetizer. 

There  was  one  remarkable  instance,  which  fell  under 
my  own  observation,  and  which  I  will  relate.  A  num- 
ber of  gentlemen,  principally  clergymen  and  physi- 
cians, were  collected  to  see  an  exhibition  of  animal 
magnetism  by  one  of  the  first  professors  of  the  art 
among  us.  After  various  experiments,  the  magnetizer 
informed  us  that  he  should  now  act  upon  the  magnet- 
izee without  her  knowing  his  design ;  and  he  asked  us 
to  keep  her  engaged  in  conversation  so  that  she  might 
not  notice  his  movements.  Accordingly,  several  gen- 
tlemen  surrounded  the  lady,  while  the   magnetizer 

seated  himself  at  a  distance,  but  kept  his  eyes  fixed 
9* 


102 


on  the  spot  where  she  sat.  I  took  my  station  with 
apparent  carelessness,  but  at  a  spot  where  I  could 
watch  both  the  parties.  For  a  long  while  he  kept  his 
gaze  upon  her,  while  he  was  designedly  screened  from 
her  by  the  gentlemen  around  her.  At  length  there 
was  a  break  in  the  circle  for  a  moment,  so  that  she 
could  see  her  friend,  the  magnetizer,  and  become 
aware  of  his  fixed  look.  Instantaneously  her  eyelids 
began  to  droop,  as  they  had  done  in  each  of  the  pre- 
vious instances,  in  which  he  had  operated  on  her ;  and 
within  a  minute  she  was  in  the  magnetic  sleep.  It 
was  perfectly  clear  that  she  was  not  influenced  until 
his  object  was  manifested  to  her. 

The  pretensions  of  magnetizers  have  gone  further. 
They  tell  you  that  their  subjects,  under  the  influence 
of  animal  magnetism,  possess  the  power  of  clairvoy- 
ance. That  is,  they  maintain  that  these  subjects  can 
see  what  is  passing  in  another  room,  or  in  another 
house,  and  even  in  another  city  from  that  in  which 
they  are  placed.  Thus,  they  are  supposed  to  see 
through  opaque  substances,  and  even  at  distances  at 
which  vision  is  impossible  ;  and  they  profess  an  ability 
to  tell  what  is  doing  in  foreign  countries.  This  power 
being  admitted,  those  who  have  faith  must  be  pre- 
pared to  believe  that  these  magnetized  persons  can 
look  through  the  solid  walls  of  the  human  body  and 


ON   SOMNAMBULISM,    ETC.  103 


point  out  the  seat  and  the  character  of  internal  dis- 
eases. To  all  this  I  have  to  say,  that  I  patiently 
examined  into  the  evidence  of  such  a  power,  and 
became  entirely  satisfied  that  it  had  not  any  existence. 

Miss  Brackett  being  left  under  my  influence  by  the 
gentleman  who  had  magnetized  her,  I  requested  her 
to  travel  with  me  in  the  spirit  to  my  own  residence. 
To  this  she  assented.  I  then  designated  the  road  by 
which  we  should  go,  and  from  time  to  time  asked  her 
to  stop  and  tell  me  what  she  saw.  She  replied  to 
me  with  great  cheerfulness  and  readiness.  But,  in 
every  instance,  her  answers  were  such  as  were  sug- 
gested by  my  remarks,  or  else  they  consisted  of  vague 
generalities.  In  this  way  I  led  her  sometimes  to  give 
answers  consistent  with  the  truth ;  but  oftener  her 
answers  were  ridiculously  inconsistent  with  it.  I  sat- 
isfied myself  that  she  was  a  very  honest  girl,  and 
failed  because  she  attempted  an  impossibility. 

It  is  well  settled  among  those  who  have  studied  the 
human  mind,  that  it  has  two  modes  of  getting  knowl- 
edge. One  is  by  sensation,  through  the  eye,  the  ear. 
etc.  The  other  is  by  consciousness,  by  which  any  one 
may  be  apprized  of  what  happens  in  his  own  mind. 
Now,  this  doctrine  of  clairvoyance  is  that  there  is 
some  other  way,  or  avenue,  by  which  knowledge  may 
ciome  into  the  mind.     I  say,  simply,  that  all  such  pre- 


104  ON  SOMNAMBULISM,    ETC. 

tensions  are  set  aside,  as  soon  as  they  are  calmly  and 
thoroughly  examined.  They  have  been  brought  for- 
ward in  all  ages ;  and  I  presume  that  there  cannot 
be  found  any  nation,  in  which  they  have  not  been 
professed  by  some  one  at  every  period.  But  when 
called  upon  for  such  proof,  as  the  case  will  admit,  the 
pretension  has  always  been  shown  to  be  groundless. 
This  has  held  true  in  our  New  England  from  the  time 
Oi  the  witches  to  that  of  the  spirit-rappers  of  the 
present  day.  The  same  pretensions  will,  probably, 
continue  to  be  held  up  in  dilBferent  modes  till  all  man- 
kind become  enlightened. 

I  know  not  when  I  shall  find  a  proper  place  for  a 
few  words  respecting  the  treatment  of  insanity,  or 
diseases  of  the  mind,  if  I  do  not  avail  myself  of  this 
letter.  Though  insanity  differs  in  respect  to  its  nature, 
as  well  as  in  respect  to  its  degree,  and  is  no  more  one 
and  the  same  thing,  than  disease  of  the  lungs  is  one 
and  the  same  thing,  yet  there  is  one  remark,  as  to  its 
treatment,  which  applies  in  almost  all  cases.  This 
remark  is  that  the  patient  can  be  treated  with  very 
much  greater  advantage  in  a  public  institution,  an 
asylum,  or  hospital,  than  in  a  private  house.  The 
patient's  own  house  is,  with  very  rare  exceptions,  just 
the  worst  place  for  him.  The  sufficient  reason  is  that 
the  patient  is,  usually,  much  more  uncomfortable  in 


105 


his  own  house  than  in  an  asylum.  Even  in  the  slight 
cases,  where  the  patient  is  said  to  be  only  ?ie?'vous,  in 
common  parlance,  if  he  will  not  engage  in  his  accus- 
tomed employments,  especially  if  he  is  dissatisfied 
with  those  around  him,  he  is  made  more  comfort- 
able at  the  asylum.  The  same  is  true  in  regard  to 
the  octogenarian,  whose  mind  seems  worn  out,  and 
who  has  become  jealous  of  his  family  and  friends,  and 
in  turn  of  every  attendant.  All  are  ready  to  agree 
that  the  violent  and  outrageous  are  best  guarded  in  a 
hospital.  Of  the  truth  of  these  statements  I  could 
bring  abundant  evidence.  The  explanation  is  this. 
The  patient,  in  his  own  dwelling,  is  accustomed  to 
exercise  certain  rights  and  enjoy  certain  privileges. 
This  is  true,  whether  it  be  father  or  son,  mother  or 
daughter.  But,  when  deranged  in  mind,  the  patient 
is  subjected  to  some  restraints,  or,  at  least,  he  thinks 
he  is ;  and  these  restraints  come  from  those,  whom  he 
regarded  as  his  friends.  He  then  believes  that  his 
friends  have  changed,  not  that  he  has  ;  and  therefore 
he  resents  what  he  considers  as  injuries,  or  insults. 
There  are  other  cases,  where  the  spirits  are  depressed, 
and  gloomy  apprehensions  engross  the  mind.  In 
these  cases  the  sight  of  near  friends  adds  to  the  trouble. 
Remove  the  patient  to  an  asylum,  and  new  trains  of 
thought  and  of  feeling  are  produced.     Perhaps  the 


106 


real  pain  of  a  separation  from  home-friends  may 
counteract  the  disposition  to  dwell  on  imaginary  causes 
of  trouble.  At  any  rate,  I  find  that  the  patient  gets 
relief  at  the  hospital. 


/ 


LETTER  VIII. 

ON  DENTITION  AND   THE   PERIOD   OF  WEANING. 

Children  usually  begin  to  have  their  first  teeth 
about  the  seventh  month,  and  continue  to  be  teething^ 
as  it  is  termed,  for  about  two  years.  I  have  known 
the  dentition  to  be  terminated  at  the  age  of  twenty-one 
months ;  and  in  another  case,  or  more  than  one,  it  has 
not  terminated  until  the  age  of  forty-two  months,  the 
subjects  being  equally  healthy.  It  is  well  known 
that,  while  the  teeth  are  coming  through  the  gums, 
children  are  liable  to  diseases  of  various  kinds,  more 
or  less  severe.  Men  who  reason  without  observing, 
are  very  liable  to  fall  into  errors.  Such  an  one  may 
discredit  my  statement,  and  ask  why  disease  should 
attend  dentition,  since  this  consists  only  in  the  forma- 
tion and  growth  of  certain  parts  of  the  body.  It  is 
not  true  that  we  suffer  during  the  whole  process  of 
forming  the  teeth.-  The  germs  are  formed  in  the 
foetus,  and  there  is  no  period  in  which  teeth  are  not 
forming,  from  birth,  until  we  arrive  at  the  age  of 


108        DENTITION   AND    PERIOD  OF   WEANING. 

twenty  or  thirty.  It  is  only  when  the  germs  are 
swelling,  and  are  ready  to  burst ;  or,  speaking  liter- 
ally, when  the  teeth  are  undergoing  the  last  rapid 
enlargement,  and  are  to  be  brought  through  the  gums, 
that  the  liability  to  disease  is  manifestly  connected 
with  dentition.  Whatever  a  reasoner  might  anticipate, 
we  know  that  the  system  sympathizes  with,  or  is 
affected  by,  any  new  or  uncommon  local  change ;  or, 
at  least,  that  it  may  be  so  affected.  This  is  more 
readily  understood  when  the  new  process  is  a  morbid 
one;  as  when,  instead  of  the  common  nutritive  pro- 
cesses, an  inflammation  is  set  up  in  any  part.  But  in 
various  normal  processes,  besides  dentition,  the  same 
thing  is  seen.  We  see  it  attending  the  changes 
belonging  to  the  age  of  puberty,  and  again  in  preg- 
nancy. Purturition  often  commences  with  a  chill, 
just  as  a  symptomatic  fever  does ;  and  lactation  almost 
always,  at  least  the  first  time,  commences  with  a  chill, 
followed  by  heat,  by  headache,  and  other  phenomena 
of  symptomatic  fever.  Even  the  catamenia  sometimes 
commence  with  a  chill,  and,  in  a  large  proportion  of 
cases,  with  constitutional  symptoms  more  or  less 
severe.  These  considerations  may  lead  the  incredulous 
more  readily  to  admit  that  the  diseases  of  infancy  are 
sometimes  caused  by  dentition  alone ;  and  in  many 
cases,  if  I  may  so  say,  favored  by  dentition,  when  not 


DENTITION   AND    PERIOD  OF   WEANING.        109 

entirely  caused  by  it.  I  shall  take  occasion  to  state 
that  it  is  not  only  in  the  first  dentition,  but  also 
during  the  growth  of  the  permanent  teeth,  that  dis- 
ease shows  itself  frequently ;  and  that  sometimes  the 
whole  constitution  undergoes  a  change,  more  or  less 
marked,  at  this  period. 

Until  the  age  when  the  teeth  show  themselves,  and 
in  some  cases  for  three  or  four  months  after  this  period 
has  commenced,  you  see  infants  expanding  in  every 
part;  those,  at  least,  who  are  properly  nourished. 
The  bones,  the  muscles,  the  internal  viscera,  are  all 
enlarging  ;  and  with  this  abundant  health  you  see  fat 
constantly  accumulating  under  the  integuments. 
Hence  comes  the  rotundity,  at  every  point,  character- 
istic of  infancy.  The  whole  business  of  the  little  one 
seems  to  be  to  eat,  laugh,  and  grow  fat ;  leaving  the 
cares  and  pains  of  life  to  its  parents.  But,  if  not  with 
the  first  tooth,  before  many  show  themselves,  the 
child  begins  to  experience  the  hardships  of  life.  If 
the  general  growth  be  not  diminished,  the  fat  is 
absorbed  somewhat,  and  thus  the  aspect  is  altered. 
The  digestive  organs  fail  to  perform  their  functions  as 
perfectly  as  before,  as  is  shown  in  various  ways. 
Even  without  any  error  of  diet,  but  particularly  if 
there  has  been  any  error,  the  food  is  vomited,  more  or 
less  digested,  or  sometimes  unchanged.  This  may 
10 


110        DENTITION   AND    PERIOD  OF   WEANING. 

occur  a  single  time,  and  pass  off  without  further 
trouble.  Next,  diarrhoea  is  a  common  occurrence. 
This  too  may  be  temporary,  produced  apparently  by 
some  article  difficult  of  digestion,  and  ceasing  when 
the  cause  is  removed.  But  as  the  powers  of  the 
stomach  are  impaired  by  continued  irritation,  trace- 
able to  the  teeth,  the  diarrhoea  becomes  more  frequent, 
and  perhaps  constant.  This  is  seen  especially  in 
August  and  September.  The  diarrhoea  may  be  in  all 
degrees,  and  may  or  may  not  be  attended  by  pain. 
These  are  among  the  most  common  phenomena  of 
teething,  and  consist,  as  you  see,  in  a  failure  of  the 
digestive  organs  and  of  the  processes  of  nutrition. 
But  the  animal  system  likewise  manifests  the  effects 
of  the  local  irritation.  The  sleep  is  no  longer  so  calm 
as  it  had  been ;  and  the  temper  is  not  so  sweet.  The 
child  gets  restless,  and  it  becomes  a  labor  to  amuse 
him.  Occasionally,  even,  convulsions  are  produced, 
accompanied  by  loss  of  consciousness  apparently,  and 
followed  by  stupor.  The  respiratory  system  and  the 
heart  partake  of  the  general  trouble,  and  so  does  the 
urinary  apparatus.  Occasionally,  after  two  or  three 
days  of  disturbance,  without  any  obvious  cause,  a  red 
sand  is  deposited  from  the  urine;  and,  in  a  day  or 
two,  the  child  is  well  again.    This  may  happen  at  any 


DENTITION   AND   PERIOD    OF   WEANING.        Ill 

period  of  life,  but  sometimes  it  appears  in  infants  to 
arise  only  from  the  dentition. 

I  have  spoken,  mostly  at  least,  of  diseases  which 
may  be  called  functional.  But  inflammation  arises  in 
various  parts  in  consequence  of  dentition.  This  shows 
itself  in  the  gums  and  cheeks  in  the  form  of  little 
ulcers,  commonly  called  canker,  but  by  my  master, 
Dr.  Holyoke,  denominated  ulcuscula  oris.  Of  this  I 
will  give  a  more  full  account  hereafter.  Inflammation 
likewise  occurs  in  the  mucous  membrane  of  the  stomach 
and  intestines,  and  is  often  recognized  by  nurses  under 
the  name  of  canker  in  the  stomach  or  bowels.  This 
inflammation  is  sometimes  in  patches  of  some  extent  ; 
but  more  commonly  it  is  limited  to  small  spots,  prob- 
ably either  the  solitary  or  the  agminated  glands  of  the 
alimentary  canal.  There  is  not  one  uniform  course 
in  these  inflammatory  afiections  of  the  mucous  mem- 
brane, and  I  have  often  thought  that  both  in  the 
alimentary  canal  and  in  the  bronchi  there  might  be 
affections  corresponding  to  what  we  call  eruptions  on 
the  skin,  and  these  varying  in  kind  and  extent.  While 
engaged  on  these  letters  I  have  learned  that  the  tal- 
ented Dr.  Simpson,  of  Edinburgh,  has  entertained  a 
similar  opinion.  I  trust  that  he  will  prosecute  this 
subject  with  the  zeal,  industry  and  sagacity,  which  are 
characteristic  of  him, 


112        DENTITION   AND    PERIOD    OF   WEANING. 

Anorexia,  vomiting,  purging,  pain,  with  or  without 
heat,  and  accelerated  pulse,  and  all  these  in  various 
degrees,  attend  the  gastritis  and  enteritis  above  men- 
tioned. The  symptoms  resulting  from  these  affections 
are  modified  by  errors  of  diet,  or  by  any  contravention 
of  the  laws  of  hygiene.  The  continuance  of  these 
affections  causes  debility,  and  often  increases  the  irri- 
tability which  belongs  to  the  infantile  age.  The  errors 
of  diet  are  the  most  noted,  as  in  truth  they  are  the 
most  frequent.  This  happens  because  the  regulation 
of  the  food  does  not  belong  to  nature,  but  depends  on 
human  discretion.  Let  me  take  this  occasion  to  point 
out  the  use  of  a  term  which  is  not  always  understood. 
Eating,  sleeping,  etc.,  are  called  non-naturals.  This 
certainly  does  not  mean  that  they  are  unnatural.  It 
means  that  Nature  does  not  determine  when  we  should 
eat,  nor  what,  nor  how  much,  nor  when  we  should 
sleep,  nor  how  long.  I  have  made  these  remarks  the 
more  distinctly,  because  I  wish  to  treat,  at  some 
length,  of  the  diet  of  infancy,  particularly  during  den- 
tition. If  I  should  not  take  this  up  by  itself,  I  should 
be  interrupted  afterwards  by  the  necessity  of  referring 
to  it  parenthetically,  as  it  were. 

It  would  seem,  at  first  sight,  useless  to  say  much 
upon  the  diet  of  infancy,  as  that  is  the  only  period  for 
which  nature  has  made  absolute  provision,     Parturi- 


DENTITION  AND   PERIOD   OF  WEANING.        113 

tioii  is  followed  by  lactation.  Nature  furnishes  tlie 
proper  food  in  the  mother's  breast;  and  to  that  breast 
the  mother  delights  to  apply  her  child,  and  there  the 
child's  instinct  enables  it  to  obtain  the  needed  supply. 
Yet  we  find  the  discretion  of  the  child's  guardian  is 
often  required,  notwithstanding  all  this  admirable  pro- 
vision. In  civilized  society  mothers  are  not  always 
vigorous,  and  cannot  furnish  all  that  is  requisite  for 
their  offspring,  nor  hold  out  so  long  as  is  needed. 
Besides,  nature  does  not  decide  up  to  what  age  a  child 
must  be  kept  at  the  mother's  breast.  It  is  then  left 
to  human  discretion  to  say  with  what,  besides  the 
mother's  milk,  an  infant  shall  be  fed ;  with  hoAV  much 
it  shall  be  fed,  and  how  often  in  the  day ;  and,  lastly, 
at  what  period  it  shall  be  weaned.  On  these  points  I 
shall  proceed  to  make  such  remarks,  as  my  experience 
seems  to  me  to  authorize.  But  do  not  imagine  that  I 
can  give  precise  rules,  for  the  same  will  not  suffice 
for  every  case.  Principles  only  can  be  furnished,  and 
a  sound  discretion  is  requisite  in  applying  them. 
Success,  sufficient  at  least  to  satisfy  the  parties  con- 
cerned, follows  various  modes  of  proceeding ;  yet  all 
are  not  equally  good. 

When  the  mother  has  milk  enough,  it  is  safe  to 
leave  the  child  to  that  alone,  in  the  early  months  of 
its  life.     Nevertheless,  there  is  a  convenience  in  feed- 
10* 


114        DENTITION  AND   PERIOD   OF  WEANING. 

ing  it  with  something  else,  once  a  day.  The  mother 
may  sometimes  be  sick,  and  sometimes  unavoidably 
separated  from  the  infant ;  then  some  food  other  than 
her  milk  must  be  given  ;  but  if  the  child  is  not  accus- 
tomed to  the  spoon,  or  the  bottle,  great  difficulty  is 
apt  to  arise.  It  is,  therefore,  expedient  to  accustom 
it,  from  the  beginning,  to  the  use  of  the  spoon.  For 
the  purpose  now  in  view  a  small  quantity  will  suffice ; 
say  from  one  to  four  table- spoonfuls.  This  little  meal 
should  be  given  early  in  the  day ;  for  if  any  uneasi- 
ness follows  in  the  day-time,  it  is  of  much  less  impor- 
tance than  it  would  be  in  the  night.  Every  precaution 
should  be  taken  to  keep  the  child  quiet  in  the  night, 
for  its  own  sake,  and  for  its  mother's  also.  At  first, 
cow's  milk,  diluted  with  three  times  its  quantity  of 
water,  is,  perhaps,  the  best  article.  The  more  fresh 
from  the  cow,  the  better  the  milk  is  for  this  purpose. 
If  it  has  been  standing  two  or  three  hours  I  would  pre- 
fer to  use  the  top  of  it,  as  I  hold  that  the  cream,  or 
buttery  part,  is  better  than  the  coagulable  or  cheesy 
part  of  the  milk.  Other  articles  may  be  used  with 
safety,  and  now  and  then  seem  even  to  be  preferable ; 
and,  if  the  mother  has  not  food  enough  for  the  child, 
larger  and  more  frequent  meals  must  be  given.  If 
goat's  milk  can  be  procured  easily,  it  should  be  given 
in  preference  to  cow's  milk ;  and,  for  a  child  with  a 


DENTITION   AND   PERIOD    OF   WEANING.       115 

very  delicate  or  feeble  stomacli,  it  should  be  sought 
for,  when  a  woman's  milk  cannot  be  had  in  sufficient 
quantity.  Water-gruel,  made  from  oatmeal  or  Indian 
meal,  is  often  used  for  young  children.  This  gruel 
depends  for  its  quality  on  the  mode  in  which  it  is 
prepared.  If  made  in  a  summary  way,  with  a  short 
boiling,  it  is  given  with  the  coarser  parts,  the  hull  of 
the  grain,  in  a  pulverized  state.  This  portion  of  the 
grain  is  indigestible,  and  from  that  very  circumstance 
is  a  laxative.  This  sometimes  makes  it  useful ;  that 
is,  useful  for  a  child  habitually  costive.  But,  like  all 
laxative  food,  and  this  more  than  some  other  articles, 
it  often  causes  flatulence  and  pain  in  the  bowels.  For 
young  infants  it  is  not  proper,  on  this  account,  for  in 
them  these  evils  are  most  readily  produced ;  but  for 
those,  more  than  three  or  four  months  old,  this  prepa- 
ration may  be  tried,  if  called  for  by  costiveness.  In 
Buch  cases  the  good  or  bad  effects  cannot  be  well 
decided  under  a  trial  of  less  than  three  or  four  days. 
When  employed  in  this  way,  the  article  may  be  given 
once  or  more  in  a  day,  as  may  be  found  necessary, 
with  reference  to  its  effects  on  the  bowels. 

The  other  mode  of  preparing  a  gruel  from  meal  is 
to  boil  it  from  two  to  four  hours.  Then  the  hull  will 
be  thoroughly  separated  from  the  nutritious,  or  farina- 
ceous  matter.     In  this   state   the   gruel   should   be 


116        DENTITION   AND    PERIOD    OF  WEANING. 

allowed  to  stand  until  the  coarse  part  has  subsided. 
The  supernatant  liquor  will  be  an  emulsion-like  arti- 
cle ;  in  fact,  a  decoction  of  the  farinaceous  grain. 
This  is  to  many  persons  more  pleasant  than  the  solu- 
tion of  arrow-root,  and  is  quite  as  mild.  Arrow- 
root is  a  very  good  article,  and  the  advantage  of  it  is 
that  it  may  be  prepared  much  more  easily  and  more 
quickly.  With  either  of  these  substances  a  little  milk 
or  cream  may  be  mixed.  When  the  child  cannot  easily 
be  made  to  take  such  food  as  I  have  described,  and  it 
is  important  that  it  should  be  fed,  because  the  mother 
cannot  fully  supply  its  wants,  some  sugar  may  be 
added.  When,  however,  the  child  will  take  the  food 
without  the  sugar,  it  should  not  be  employed.  True,  it 
is  often,  and  perhaps  commonly,  given  with  impunity ; 
but,  when  the  stomach  gets  feeble  and  delicate,  the 
sweetened  food  is  apt  to  become  sour ;  then  the  child 
cannot  be  induced  to  take  the  food  without  the  sugar, 
and,  often,  great  inconvenience  follows. 

It  is  well,  then,  to  feed  the  infant  once  a  day,  for 
the  benefit  of  haying  it  accustomed  to  take  its  food  in 
this  way  ;  and  it  may  be  necessary  to  feed  it  much 
more  when  the  mother  has  not  a  sufficient  quantity 
of  nourishment  for  it.  In  either  case  the  food  must 
De  liquid  and  very  simple  in  its  character.  Various 
other  substances  may  be  used.     Sago  is  among  those 


DENTITION  AND  PERIOD  OF  WEANING.        117 

which  are  easily  procured.  If  the  child  must  depend 
largely  on  feeding ,  as  it  is  termed  by  the  nurses, 
it  is  best  to  get  it  more  and  more  accustomed  to  the 
cow's  milk,  until  this  becomes  the  larger  part,  and  at 
last  the  whole  of  the  article  administered.  The  great- 
est inconvenience  of  this  milk  is  that  it  is  apt  to  occa- 
sion costiveness.  If  it  does  so,  oatmeal  may  be  used 
with  it,  in  such  a  manner  as  to  include  its  coarse 
parts.  Adding  water  to  milk  is  thought  to  weaken  it, 
as  water  operates  when  added  to  wine  or  alcohol.  I 
apprehend  that  milk  is  not  in  any  sense  weakened  by 
a  mixture  of  water.  In  the  stomach  the  milk  goes 
for  the  same  thing,  the  quantity  being  the  same, 
whether  water  is  added  or  not.  Yet  there  is  usually 
an  advantage  in  adding  water  for  a  child ;  the  cow's 
milk  is  stronger,  contains  more  nourishment  than  a 
woman's  milk.  If  a  child  is  eager  for  quantity, 
whether  from  thirst  or  what  not,  it  would  take  more 
cow's  milk  at  a  time,  than  it  could  well  bear.  The 
evil  is  obviated  by  adding  water,  as  thus  the  quantity 
is  increased  without  giving  too  much  nutritious  matter 
at  once. 

I  suggested  a  measure  for  the  meal  of  a  very  young 
infant ;  but  if  it  needs  more  food  than  the  Jiother  can 
furnish,  the  quantity  at  a  meal  must  be  increased,  and 
the  frequency  of  its  meals  also,  in  proportion  to  the 


118         DENTITION  AND  PERIOD  OF  WEANINO. 

case.  Here  watchfulness  and  discretion  are  requisite; 
for  children,  as  well  as  adults,  require  very  different 
quantities  of  food.  A  very  young  infant,  taking  lit- 
tle at  a  time,  may  require  to  have  a  meal  once  in  two 
hours,  whether  from  the  breast  or  the  bottle.  But, 
as  soon  as  possible,  the  interval  between  its  meals 
should  be  increased  to  three  hours ;  and  I  think  it 
best  to  make  the  interval  four  hours  at  six  months 
after  birth.  It  is  impossible,  however,  in  most  in- 
stances, to  make  mothers  adhere  to  exact  rules  in  this 
matter.  When  a  child  feeds  much,  the  rules  should 
be  more  rigidly  enforced,  than  when  it  is  nursing 
only,  or  principally. 

It  is  important  to  direct  that  liquid  food  should 
be  administered  to  infants  just  tepid,  as  near  to  the 
warmth  of  the  mother's  milk  as  may  be.  The  use 
of  hot  liquids  to  new-born  infants  is  especially  inju- 
rious, often  causing  an  aphthous  mouth. 

The  time  comes  sooner  or  later  for  children  to  use 
solid  food,  as  a  part  of  their  nourishment.  Nature 
has  not  marked  out  any  exact  period  for  this,  unless 
we  consider  the  coming  of  the  teeth  as  a  sufficient 
guide.  To  a  certain  extent  it  is  so.  As  long  as  a 
child  is  strong,  and  grows  well,  and  shows  the  beauti- 
ful rotundity  of  infancy,  one  need  not  be  anxious  to 
make  any  change  in  his  food.     Yet,  in  a  view  of  all 


DENTITION  AND  PERIOD  OF  WEANING.         119 

his  coming  wants,  and  of  the  possible  failure  of  the 
supply  from  his  mother,  I  think  it  well  to  begin  grad- 
ually to  give  him  bread,  in  very  small  quantities,  in 
the  fifth  or  six  month.  He  should  be  watched,  as  in 
every  change  of  diet,  to  see  how  it  agrees  with  him. 
If  he  is  always  uneasy  after  it,  or  if  his  alvine  dis- 
charges show  any  evil,  the  bread  must  be  given  up 
for  a  time.  Commonly,  good  white  bread  is  easily 
digested  at  the  age  mentioned,  if  the  quantity  is 
small.  As  the  child  grows  older  the  quantity  may 
be  increased,  until  the  bread  constitutes  an  important 
article  of  its  food.  Other  vegetable  substances  may 
be  gradually  introduced,  such  as  rice  and  potatoes  well 
cooked.  But  these  are  not  necessary,  where  the  bread 
is  well  borne.  If  the  child  be  habitually  costive, 
bread  made  from  coarse  wheat  flour  (wheat  meal) 
may  be  given ;  or  plain  molasses  gingerbread,  or 
fruit.  The  hard  fruits,  apples  especially,  should  be 
cooked, — roasted  or  baked.  In  summer  the  various 
berries  are  often  useful. 

There  comes  a  time  when  a  child  should  have  some 
gratification  to  his  carnivorous  propensity.  There  is 
not  any  precise  time  at  which  this  is  requisite.  Chil- 
dren, who  are  vigorous  and  grow  well,  can  afford  to 
defer  it.  The  pale,  thin  and  feeble  child  should  have 
an  early  opportunity  to  show  whether  he  loves  flesh  or 


120        DENTITION  AND  PERIOD  OF  WEANING. 

fishj  and  whether  he  can  digest  the  same  and  thrive 
upon  it.  Any  one  who  has  teeth  may  begin  with  a 
chicken-bone,  and,  if  he  is  pleased  with  the  indul- 
gence, may  have  a  little  tender  meat,  very  finely 
minced,  once  in  a  few  days.  According  to  the  effects, 
the  indulgence  may  be  gradually  increased.  It  is 
well  that  a  child  should  get  the  habit  of  taking  a  lit- 
tle meat  daily,  or  frequently,  before  he  has  completed 
his  first  year. 

I  have  said  something  of  the  frequency  of  meals ; 
but  there  is  one  remark,  connected  with  that  matter, 
which  I  have  reserved  that  I  might  make  it  emphati- 
cally. This  is  that,  if  possible,  the  infant  should  be 
made  to  pass  six  or  eight  hours  in  the  night  without 
food.  In  the  mother's  phrase,  the  child  should  not 
nurse  in  the  night.  This  is  mutually  beneficial  to 
mother  and  child.  The  proper  rest,  which  the  mother 
gets  in  this  case,  enables  her  to  support  the  strain 
which  is  made  upon  her,  and  thus  indirectly  is  bene- 
ficial to  the  child.  This  is  a  sufficient  reason  for  the 
practice ;  for  among  us  there  are  few  mothers  who  do 
not  shrink  under  the  fatigue  of  nursing  their  children. 
But  it  is  directly  beneficial  to  the  child,  also,  whose 
stomach  is  the  better  for  this  full  rest  once  in  twenty- 
four  hours.  Children  thus  treated  are,  usually,  more 
happy  in  the  day,  than  those  who  nurse  much  in  the 


DENTITION  AND  PERIOD  OF  WEANING.  121 

night,  and  increase  quite  as  fast  in  flesh  and  strength. 
That  there  are  restless  children,  who  cannot  be  trained 
up  in  this  way,  I  admit ;  but  they  are  comparatively 
very  few.  Nothing  is  lost  by  the  trial ;  and,  if  this 
be  made  in  good  earnest,  success  often  follows,  even 
in  cases  which  seem  desperate.  The  best  chance  for 
success  is  found  in  beginning  the  practice  from  the 
very  first  night. 

One  other  direction  I  should  not  omit.  I  have 
mentioned  feeding  during  the  period  of  nursing.  I 
have  had  reference  in  ail  this  to  a  child  in  health. 
When  attacked  by  any  acute  disease,  whether  in  the 
digestive  organs  or  elsewhere,  the  child  should  be 
kept  to  the  breast  alone,  if  enough  for  its  support  can 
be  found  there.  As  the  food  should  be  diminished  in 
quantity,  in  such  a  case,  this  is  not  very  difficult.  It 
is  the  less  so,  because  the  child  commonly  falls  off  in 
appetite  in  such  a  case.  It  is  true  that  he  may  want 
to  nurse  because  he  is  thirsty.  The  difficulty  in 
this  respect  may  be  obviated  by  small  draughts  of 
water,  either  warm  or  cold,  as  may  seem  most  grate- 
ful to  him. 

We  come  now  to  the  great  change  in  the  infant's 

diet,  weaning  ;  weaning  from  the  breast.     This  is  a 

change,  to  which  the  young  mother  looks  forward  with 

great  anxiety.     It  is  right  that  she  should  do  so.     It 

11 


122         DENTITION  AND  PEKIOD  OF  WEANING. 

is  worthy  a  careful  consideration.  At  the  risk  of 
seeming  to  exalt  this  matter  unduly,  I  will  say  that 
it  is  one  of  the  great  events  in  life.  The  child's  sub- 
sequent health  and  vigor  of  constitution  may  depend 
upon  the  proper  timing  of  this  great  change. 

Undoubtedly  it  is  best  that  the  weaning  should 
take  place  gradually  —  very  gradually.  But  circum- 
stances often  make  it  necessary  to  be  somewhat  abrupt 
in  making  the  change.  However  made,  in  a  very 
few  days  after  it  has  taken  place  the  child  loses  the 
faculty  of  drawing  the  breast,  and  likewise  the  mother 
ceases  to  form  milk.  Thus  the  separation  of  child 
from  mother,  in  this  particular,  once  made,  is  made 
forever.  Especial  care,  then,  should  be  taken  not  to 
do  it  before  the  child  is  sufficiently  advanced  in  age, 
and   not   at  a  time  when  it  is  peculiarly  liable   to 


The  months  of  July,  August,  September  and  Octo- 
ber, are  those  in  which  infants  are  most  liable  to  sick- 
ness. It  is  in  August  and  September  that  this  is 
most  especially  true.  The  child,  who  has  kept  well 
till  October,  will  commonly  escape  the  autumnal  dis- 
eases in  that  month ;  more  especially  after  the  first 
week  in  it.  But  these  remarks  apply  to  children  who 
are  teething.  Those  who  have  not  begun  to  have 
teeth  at  the  season  described,  will  pass  through  it  as 


DENTITION  AND  PERIOD  OF  WEANING.         123 

well  as  children  who  have  got  all  their  first,  or  milk 
teeth.  These  take  their  turn  in  the  second  summer 
of  their  lives,  in  which  the  process  of  dentition  will 
be  going  on  rapidlj.  All  this  is  to  be  kept  in  view 
when  fixing  upon  the  period  for  weaning. 

When  I  commenced  practice,  I  was  unable  to  get  at 
any  rules  on  this  subject.  The  first  question  was,  at 
what  age  children  should  be  weaned.  Neither  the 
books  to  which  I  had  access  then  or  since,  nor  the 
medical  fathers  around  me.  gave  any  reliable  informa- 
tion on  the  point.  Circumstances,  which  I  will  not 
detail,  caused  it  to  arrest  my  attention.  Then  I  was 
soon  led  to  suspect  that  the  age  was  not  the  only 
thing  to  be  considered,  but  the  season  also.  It  would 
have  required  years  to  have  obtained  sufficient  knowl- 
edge on  this  subject  by  my  own  observation.  Then  I 
began  to  draw  from  all  the  mothers  I  met  with,  not 
their  opinions,  but  their  experience.  If  I  asked  for 
opinions,  the  mothers  and  experienced  nurses  told  me 
that  I  must  look  to  the  almanac,  and  be  decided  by  the 
particular  phase  of  the  moon  in  deciding  upon  the  time 
of  weaning.  My  method  of  inquiry  was  this  :  I  asked 
the  matron  how  many  children  she  had  had ;  and,  in 
regard  to  each  one,  in  what  month  it  was  born  ;  then 
at  what  age  it  was  weaned ;  and  then  what  was  its 
health  subsequently,  and  especially  in  the  summer 


124         DENTITION  AND  PERIOD  OF  WEANING. 

months  after  its  weaning.  Comparing  what  I  learned 
in  this  waj  with  what  passed  under  my  own  obser- 
vation, I  came  to  these  conclusions,  which  I  published 
more  than  forty  years  ago  in  the  "New  England 
Journal  of  Medicine  and  Surgery."  I  will  give  you 
an  extract  from  a  paper  you  will  find  in  that  Jour- 
nal, entitled  Remarks  on  the  Morbid  Effects  of 
Dentition. 

"  Children  are  benefited  by  living  principally  on 
the  breast  for  twelve  months;  their  vigor  is  evi- 
dently impaired,  in  almost  all  cases,  when  they  are 
nursed  less  than  nine  months.  The  safest  period  of 
the  year  for  weaning  is  from  the  middle  of  October  to 
the  middle  of  March ;  provided  they  be  not  weaned 
under  ten  months  after  December,  under  eleven  after 
January,  nor  under  twelve  after  February.  Children 
who  are  weaned  at  the  age  of  twelve  months  in  March 
are  ordinarily  safe ;  those  who  are  weaned  at  this  age 
in  April  are  less  so — one  half  of  them,  perhaps,  suf- 
fering severely  in  the  subsequent  summer  or  autumn. 
In  May  the  danger  increases ;  and  in  the  four  sub- 
sequent months,  if  a  child  of  any  age  be  weaned,  it 
will  in  most  cases  be  very  sick  before  the  middle  of 
the  October  ensuing.  The  disease  does  not  imme- 
diately follow  the  weaning  ;  though  in  many  cases  the 
diarrhoea  of  teething  children  ensues  at  once.     But 


DENTITION  AND  PERIOD  OF  WEANING.         125 

the  instances,  in  which  children,  who  are  weaned 
between  May  and  October,  escape  severe  cholera 
infantum,  are  extremely  rare  indeed.  It  must,  how- 
ever, be  noted  that  in  some  years  the  seasons  are  much 
more  favorable  to  the  health  of  teething  children  than 
in  others.  It  must  also  be  noted  that  the  limits,  which 
have  been  mentioned,  must  be  varied  by  particular 
circumstances.  First,  the  seasons  vary  two  or  three 
weeks  in  different  years.  Second,  something  will 
depend  on  the  constitution  of  the  child.  But  we  must 
beware  not  to  place  too  much  reliance  on  this  circum- 
stance, especially  on  the  general  appearance,  on  the 
fatness,  etc.  Those  children  who  love  meat  and  rel- 
ishing food,  who  digest  their  food  well,  who  are  in 
perfectly  regular  habits  as  to  their  alvine  evacuations, 
and  who  sleep  well,  are  the  best  qualified  to  bear  a 
deviation  from  the  rules  suggested  above." 

In  giving  the  precise  remarks  contained  in  the  fore- 
going extract,  it  was  not  meant  that  nature  is  limited 
by  exact,  straight  lines.  There  is  a  difference  in  the 
constitutions  of  children,  and  the  seasons  are  constantly 
varying  from  year  to  year.  In  remarks,  such  as  are 
given  above,  we  make  approximations  to  the  truth. 
Tliey  are  founded  on  averages,  and  are  not  supported 
by  each  individual  instance.  However,  I  may  sa;^ 
that  the  rules  deduced  from  them  are  the  most  safe  at 
11* 


126       DENTITION   AND    PEHIOD    OF  WEANING. 

W^hich  I  was  able  to  arrive  in  1812 ;  and  I  may  repeat 
the  same  as  to  the  present  year,  1855.  I  have  been 
obliged  to  discuss  the  subject  in  every  intervening 
year  between  these  two  dates;  and  many  a  mother 
has  shown  me  a  healthy  child  whom  she  has  reared 
while  disregarding  the  rules  I  have  given.  More  than 
this,  I  have  seen  whole  families  of  children  reared  in 
safety  without  any  aid  from  a  woman's  milk.  I  be- 
lieve, however,  it  is  only  two  or  three  such  families  I 
have  seen.  But  the  question  is  not  to  be  decided  by 
a  few  selected  instances.  I  know  that  many  men  are 
holding  up  their  heads,  and  are  sound  in  mind  and 
limb,  who  have  been  repeatedly  exposed  in  hot  battles. 
Yet  no  one  pretends  that  a  man  is  not  in  great  danger 
in  such  battles.  Many  are  killed,  and  many  maimed. 
I  should  add  that  my  experience  has  been  limited 
mainly,  though  not  entirely,  to  this  city  of  Boston.  I 
know  very  well  that  people  living  in  the  open  country, 
not  in  crowded  villages,  if  they  avail  themselves  of 
their  advantages,  and  keep  their  children  much  in  the 
open  air,  find  it  comparatively  easy  to  rear  infants. 
Yet,  in  their  proportion,  the  same  troubles  arise  among 
t;hem  as  in  the  cities.  They  have  the  best  chances, 
yet  they  experience  some  evils  which  we  escape  in 
cities.  I  am  quite  convinced  that  our  city  children 
get    vigor  by  passing    the    summer    and   autumnal 


DENTITION   AND    PERIOD    OF   WEANING.        127 

months  in  the  country ;  but  they  more  frequently  get 
sick  there;  that  is,  they  are  oftener  attacked  with 
acute  diseases,  than  when  in  the  city.  This  remark 
has  reference  more  to  children  after,  than  during  the 
period  of  dentition.  If  asked  for  an  explanation  of 
this  difference,  I  reply  that  I  suspect  it  to  be  owing  to 
more  frequent  exposure  to  evening  air  in  the  country. 
I  am,  however,  more  sure  of  the  difference  above 
stated,  than  of  the  cause. 

It  sometimes  happens  that,  when  a  child  is  weaned 
from  the  breast,  it  immediately  becomes  very  sick.  It 
rejects  whatever  is  taken  into  the  stomach,  manifests 
a  deadly  nausea,  has  incessant  thirst,  but  no  appetite 
for  the  food  which  is  offered  to  it,  is  extremely  pros- 
trated, and  sometimes  within  twenty-four  hours,  often 
within  three  or  four  days,  gets  the  cadaverous  aspect 
of  a  victim  to  the  Asiatic  cholera.  In  these  cases, 
when  so  extreme,  death  often  follows  within  a  few 
days  ;  but  some  recover  after  the  worst  symptoms.  If, 
under  these  circumstances,  you  restore  the  child  to 
the  breast,  it  revives  within  twenty-four  hours,  and  is 
soon  well  again.  Sometimes  such  a  child  will  not 
take  the  breast  of  a  stranger,  and  its  mother,  or  its 
foster-mother,  cannot  be  had.  In  that  case,  if  you  can 
find  a  woman  who  can  milk  out  the  nutritious  fluid, 
and  you  give  that  to  the  child  warm  from  the  breas^ 


128       DENTITION   AND    PERIOD    OF   WEANING. 

the  whole  purpose  is  answered.  When  a  child  is  made 
sick,  as  I  have  described,  if  you  give  it  just  such  food 
as  it  had  taken  and  borne  well  on  the  preceding  days 
or  weeks,  and  in  the  same  quantities,  it  cannot  bear  it. 
But,  after  restoring  it  to  the  use  of  the  human  milk, 
it  soon  bears  the  same  food  very  well ;  and  even  a  very 
little  human  milk  is  sufficient  to  keep  the  infant's 
stomach  in  such  a  state  as  to  bear  the  other  food. 
Under  these  circumstances,  I  have  been  in  the  habit 
of  saying  that  the  human  milk  kept  the  stomach  in 
good  humor. 


LETTER  IX. 

OK    CHOLERA    INFANTUM,    THE    SECOND   DENTITION, 
AND    ULCUSCULA    ORIS. 

In  the  last  letter  I  took  notice  of  diarrhoea  in 
teething  children.  In  the  simplest  form,  this  comes 
from  the  use  of  an  indigestible  substance  as  it  may 
at  any  age.  ,  But  at  the  period  of  dentition,  every 
disorder  attracts  more  attention  than  at  a  later  period 
of  life,  and  very  justly.  By  observing  such  an  occur- 
rence, in  connection  with  the  diet  employed,  we  learn 
what  articles  to  avoid  in  an  individual  case.  But  the 
same  article,  and  in  the  same  quantity,  is  not  always 
followed  by  the  same  effects ;  and  even  without  any 
error  as  to  the  quality  of  the  food,  the  diarrhoea  takes 
place.  If  there  is  no  error  as  to  quality  or  quantity, 
we  must  infer  that  the  organs  of  digestion  are  wanting 
in  power.  This  may  happen  temporarily  from  vari- 
ous disturbing  causes.  It  is  brought  on  gradually 
during  dentition,  from  the  wasting  of  strength  incident 
to  that  period.     Undue  quantity  may  have  this  effect 


130 


and  is  particularly  apt  so  to  do,  when  the  digestive 
organs  have  become  weakened.  The  remedy  for  the 
evils  I  have  now  stated  consists  chiefly  in  correcting 
the  errors  of  diet,  where  we  are  able  to  understand 
them.  When  the  natural  efforts  do  not  appear  to 
effect  a  removal  of  the  offending  matters,  some  castor 
oil  or  other  cathartic  should  be  given.  After  this  the 
chalk  mixture  should  be  used,  until  the  discharges  are 
less  frequent  and  more  natural ;  and  if  this  remedy 
should  not  cause  an  amendment  in  twenty-four  hours, 
some  opiate  may  be  added  to  it.  The  tincture  of 
opium  may  be  given  in  the  dose  of  one  or  two  drops  to 
a  teething  child,  and  repeated  to  the  extent  of  four 
times  a  day.  In  obstinate  cases  the  quantity  may  be 
increased,  but  always  with  great  watchfulness  at  this 
tender  age. 

Diarrhoea,  arising  from  too  great  a  quantity  of  food, 
may  occur  in  a  healthy  infant  at  any  time.  I  am 
tempted  to  leave  the  period  of  dentition  for  a  moment, 
m  order  to  point  out  the  circumstances,  under  which 
a  diarrhoea  occurs,  before  that  'period.  I  refer  to  a 
case,  which  is  not  uncommon  to  infants  in  the  first 
few  months  after  birth,  which  is  not,  I  think,  well 
understood ;  and  for  which  too  severe  a  treatment  by 
medicine  is  often  tried,  and  tried  fruitlessly.  This 
infantile  diarrhoea  is  not  of  serious  importance.     The 


131 


discnarges  are  frequent,  loose,  though  not  watery,  and 
oftentimes  green.  Thej  are  sometimes  attended  with 
pain,  but  this  is  not  serious.  Meanwhile,  no  weak- 
ness nor  emaciation  takes  place ;  on  the  contrary,  the 
child  grows  apace.  While  the  mother  is  speaking  of 
his  alarming  disease,  the  infant  by  its  smiles  brings 
her  smiles  also,  and  she  becomes  puzzled  as  to  the 
conclusion  to  be  arrived  at.  It  is  on  these  circum- 
stances —  that  the  nutrition  goes  on  well,  and  that  the 
general  health  is  maintained  —  that  you  may  place 
your  reliance.  The  cause  is  principally  the  undue 
quantity  of  milk  which  the  child  takes  from  its  mother. 
I  will  not  say  this  is  the  only  cause  ;  for  I  have  some- 
times suspected  some  fault  in  the  milk.  Ordinarily, 
however,  if  you  can  persuade  the  mother  to  nurse  the 
child  less  frequently,  the  diarrhoea  ceases,  and  the 
child  continues  to  flourish.  I  would  not  have  you 
understand  that  I  learned  all  this  at  once.  Usually, 
before  a  case  of  this  sort  came  into  my  hands,  the 
mother  or  the  nurse  had  administered  various  cathar- 
tics, most  especially  magnesia  and  castor  oil.  These 
brought  away  the  green  matter,  and  then,  perhaps, 
more  healthy  dejections  followed.  But  the  amend- 
ment would  seldom  continue  more  than  one,  or  two 
days.  In  my  early  years  I  would  try  rhubarb,  and 
afterwards  chalk-mixture,  but  without  any  permanent 


132  ON   CHOLERA  INFANTUM,    ETC. 

benefit.  At  length,  I  became  satisfied  that  medicine 
was  worse  than  the  disease ;  and  that,  if  not  arrested, 
the  diarrhoea  was  not  seriously  injurious.  In  sucn 
cases,  I  have  always  taken  care  to  explain  the  case  to 
the  mother,  that  she  might  not  think  it  equally  safe 
to  neglect  a  diarrhoea  in  a  teething  child. 

To  return  from  this  digression.  I  will  now  state 
that,  in  the  sickly  months,  children  are  often  affected 
with  a  more  grave  disease  than  diarrhoea,  and  which 
is  commonly  known  as  the  Cholera  Lifantum, 
Under  this  name,  however,  you  do  not  always  find 
what  appears  to  be  one  simple  disease.  The  term 
cholera,  you  know,  was  originally  applied  to  diseases 
in  which  bile  made  its  appearance ;  and  this  bile  was 
supposed  to  be  the  proximate  cause.  To  this  day, 
persons  out  of  the  profession,  and  very  many  in  it, 
think  of  bile  as  a  cause  of  disease,  and  do  not  look 
behind  it  for  any  cause  more  within  their  control. 
You  know  that,  if  you  get  a  mote  in  the  eye,  the 
lachrymal  gland  pours  out  tears,  which  are  well  calcu- 
lated to  wash  it  away.  If  any  inflammation  occurs  on 
the  conjunctiva,  the  same  flow  of  tears  takes  place. 
So  any  acrid  substance  in  the  mouth,  or  an  inflamma- 
tion in  its  mucous  membrane,  may  cause  a  flow  of 
liquid  from  the  salivary  glands.  Precisely  so,  as  I 
apprehend,  acrid  substances  in  the  stomach,  or  duo- 


ON   CHOLERA   INFANTUM,    ETC.  138 

denum,  or  inflammation  of  the  mucous  membrane  of 
these  organs,  will  cause  a  great  flow  of  bile  into  them. 
An  occasional  vomiting  of  bile,  therefore,  or  a  bilious 
diarrhoea,  may  arise  from  a  transient  cause,  of  which 
you  have  instances  in  the  efiects  of  antimonial  and 
other  medicines.  But,  when  this  vomiting  or  purging 
of  bile  continues  after  all  irritating  causes  are  removed, 
you  may  infer  that  it  is  not  an  acrid  substance,  but 
an  inflammation  of  the  parts  above  mentioned,  which 
gives  occasion  to  the  flow.  It  is  proper  to  add  that 
various  circumstances  are  to  be  taken  into  considera- 
tion before  this  conclusion  is  admitted  as  certain. 
Thus,  for  instance,  an  irritation  in  some  distant  organs, 
as  in  the  kidneys,  or  the  uterus,  may  cause  a  vomiting 
of  bile.     But  I  need  not  go  further  upon  this  point. 

I  will  now  state  that  when  gastritis,  or  enteritis 
occurs,  you  will  find  produced  the  phenomena  of 
cholera  infantum.  It  is  more  especially  when  the 
inflammation  is  limited,  as  above  stated,  to  the  stomach 
and  duodenum,'  that  this  takes  place.  But,  in  the 
progress  of  the  disease,  inflammation  sometimes  occurs 
in  the  other  intestines,  and,  of  course,  the  symptoms 
are  modified.  Vomiting  and  purging  are  the  leading 
symptoms  of  cholera ;  but,  alone,  they  do  not  consti- 
tute the  formidable  disease,  and  not  even  if  anorexia 
be  added  to  them.  The  great  distinction  arises  from 
12 


184 


the  constitutional  symptoms,  added  to  those  which  are 
local ;  and  among  these  constitutional  symptoms,  the 
prostration  of  strength  and  shrinking  of  the  whole 
body  are  the  most  important.  It  is  not,  then,  the  color 
of  the  discharges,  nor  the  frequency  of  them,  which 
makes  the  distinction  between  cholera  infantum  and 
iiarrhcea.  The  difference,  pathologically,  consists,  as 
£  believe,  in  the  existence  of  an  inflammation  in  the 
mucous  membrane  of  the  stomach  and  duodenum  in  the 
cholera ;  while,  in  the  diarrhoea,  it  is  probably  lower 
down  in  the  canal,  if  anywhere,  that  inflammation 
exists.  It  is  not  requisite  that  the  inflammation  be 
very  severe  to  produce  the  effects  pointed  out.  The 
difference  as  to  symptoms  is  that  in  the  cholera  there 
is  an  altered  countenance,  a  shrinking  of  the  features, 
prostration  of  strength  and  spirits,  and  at  times  dis- 
tress, or  stupor,  or  these  two  alternating.  Pain 
accompanies  diarrhoea  as  well  as  cholera ;  but  in  the 
latter  it  is  often  very  extreme,  and  the  sufferer 
rejects  all  aid  and  comfort,  seeming  to  believe  that  no 
one  can  help  him.  This,  however,  is  occasional,  and 
does  not  occur  in  every  case.  Common  febrile  symp- 
toms also  are  frequent  attendants  on  this  disease. 

As  the  actual  disease  varies  in  its  extent  and 
severity,  and  as  the  constitution  varies  in  its  readiness 
to  sympathize  with  the  local  affection^  so  must  the 


ON   CHOLERA   INFANTUM,    ETC.  135 

symptoms  vary.  In  some  instances,  mostly  in  July 
or  August,  the  disease  is  quite  acute.  The  child  is 
taken  down  at  once,  and  overpowered,  and  the  disease 
may  prove  fatal  in  a  few  days ;  but  this  is  rare. 
More  commonly,  the  patient  rallies  from  an  acute 
attack,  or  the  disease  commences  more  gently,  and  in 
either  case  it  continues,  varying  in  severity.  Thus, 
it  may  continue,  fresh  attacks  occurring  from  time  to 
time,  through  xlugust,  September,  and  later.  It  may 
prove  fatal  at  different  periods,  or  cease  altogether, 
but  leaving  the  patient  greatly  reduced.  When  con- 
tinuing for  a  length  of  time,  the  patient  loses,  after 
each  new  attack,  both  flesh  and  strength. 

This  disease  is  seldom  fatal  to  a  nursing  child. 
When  not  nursing,  from  the  want  of  the  appropriate 
food,  the  child  does  not  get  up  well  from  the  first  or 
subsequent  attacks,  and  the  disease  becomes  compli- 
cated with  dyspepsia.  Then  there  is  a  great  need  of 
food,  and  often  a  great  craving  for  it,  and  yet,  perhaps, 
nothing  but  the  human  milk  can  be  digested.  You 
will  see  such  a  child  reduced  to  a  skeleton,  tended  on 
a  pillow,  the  skin  so  loose  that  it  may  be  wrapped 
over  the  subjacent  parts,  life  being  doubtful  from  day 
to  day,  supported  only  by  wine,  or  even  by  ardent 
spirits,  and  yet  ultimately  recover. 

While  other  symptoms  vary,  the  diarrhoea  never,  or 


136  ON   CHOLERA   INFANTUM,    ETC. 

very  rarely,  ceases.  This  is  kept  up  from  the  imperfect 
digestion  (and  there  the  stomach  is  in  fault),  and  from 
the  irritable  state  of  the  bowels,  dependent  sometimes 
on  inflammation,  or  slight  ulceration.  Consider,  then, 
that  the  dejections  vary  from  the  kind  of  food  received, 
the  more  or  less  perfect  digestion  of  this  food,  the 
mixture  of  the  secretions,  which  are  poured  into  the 
bowels,  healthy  or  morbid,  and,  lastly,  from  the  greater 
or  less  embarrassment  attending  the  passage  of  these 
materials  through  the  canal.  And  remember  that 
this  difficulty,  as  to  the  passage  of  the  materials, 
operates  more  especially  in  holding  back  the  proper 
faeces  derived  from  the  food;  for  the  secretions,  not 
being  solid,  are  more  easily  transmitted.  Now,  if  you 
would  understand  such  a  case,  you  must,  day  by  day, 
ascertain  the  following  facts :  first,  the  ai'ticles  taken, 
how  much  of  each,  and  at  what  periods,  including  the 
liquids ;  second,  how  far  any  discomfort  has  followed 
a  meal,  whether  this  be  pain  or  uneasiness  only ;  also, 
whether  there  has  been  heat,  heaviness,  or  restlessness ; 
and,  third,  the  dejections,  their  number  and  character. 
These  dejections  must  be  carefully  analyzed ;  I  do  not 
mean  by  chemical  means,  but  by  an  estimate  of  the 
proximate  elements  which  compose  them.  Each  dis- 
charge should  be  kept  by  itself,  and  they  should  be 
placed  in  the  order  in  which  they  take  place,  aftd  you 


ETC.  137 

should  take  note  of  the  periods  at  which  they  occurred. 
You  should  then  observe,  in  respect  to  each,  whether 
it  contains  any  faeces,  and  how  much ;  and  whether 
the  material  is  in  its  crude  state,  or  partially  digested ; 
and,  then,  how  much  there  is  of  mucus,  watery  fluid 
and  bile ;  to  which  I  may  add  blood,  as  this  is  some- 
times added  to  the  morbid  materials.  Now,  that  dis- 
charge is  the  best  in  which  there  are  the  most  faeces  ; 
more  especially  if  these  are  truly  faeces,  and  not  an 
undigested  matter.  This  is  best,  at  least  for  this  rea- 
son, that  it  shows  the  organs  to  be  in  a  condition  so 
healthy  and  so  vigorous  as  to  transmit  the  faeces;  for 
one  of  the  worst  things  in  this,  as  in  other  diseases  of 
the  bowels,  is,  that  the  lame  intestines  cannot  perform 
their  duty.  Let  me  impress  this  by  saying  that  you 
should  always  insist  upon  learning  from  the  nurse, 
when  you  do  not  see  the  discharges,  what  the  quantity 
is ;  for,  even  a  good  nurse  is  apt  to  think  it  is  enough 
if  she  tells  you  the  color,  adding,  perhaps,  that  the 
stool  was  loose,  or  was  not  so.  Next,  the  mucus  is 
more  or  less,  first,  according  to  the  inflammation  of 
any  patches  in  the  intestines,  which  at  a  certain  period 
become  covered  with  extra  mucus ;  and,  second,  it  is 
mcreased  by  the  irritating  materials  which  are  passed 
over  these  surfaces.  Indeed,  very  irritating  matters 
will  provoke  the  formation  of  mucus  in  parts  iwt 
12* 


138 


inflamed.  A  watery  fluid,  diluting  the  alvine  dis- 
charges, may  be  poured  out,  like  mucus  from  the 
surface  of  the  mucous  membrane,  consequent  upon 
either  irritation  or  inflammation.  Generally,  this  fluid 
denotes  the  presence  of  peculiar  irritants,  such  as 
neutral  salts ;  and  this  may  be  seen  in  common  diar- 
rhoea ;  or  it  is  poured  out  from  surfaces  at  an  early 
stage  of  inflammation,  just  as  you  often  see  in  the 
nasal  catarrh,  in  its  early  stages,  before  a  more  viscid 
secretion  takes  place.  Bile  is  another  of  the  fluids 
found  in  the  discharges ;  and  this  should  be  found  in 
every  alvine  discharge,  and  intimately  mixed  with  its 
other  elements.  This  should  be  found,  I  say,  in  a 
state  of  health.  An  undue  proportion  of  bile  is  found 
in  various  cases,  but  in  this  disease,  mostly  from  irri- 
tation of  the  mucous  membrane  of  the  stomach,  or  of 
the  duodenum.  This  matter  has  been  before  adverted 
to.  But  there  is  a  stage  of  inflammation  in  which  the 
parts  are  left  dry  for  a  while,  or  comparatively  so,  the 
neighboring  secretions  not  having  come  to  their  relief. 
In  this  way,  I  believe,  the  efiusion  of  bile  into  the 
canal  is  sometimes  suspended,  and  is,  therefore,  want- 
ing in  the  dejections.  There  is  still  another  cause  for 
the  absence  of  bile,  the  same  as  for  the  absence  of 
faecal  matter ;  that  a  portion  of  the  intestine  cannot 
transmit  the  materials  brought  to  it,  so  that  the  dis- 


ON   CHOLERA   INFANTUM,    ETC.  139 

charges  consist  of  those  matters  only  which  come  from 
the  parts  below  the  obstruction.  This  is  what  is  con- 
stantly happening  in  dysentery ;  and  which  happens 
likewise  in  cholera  infantum,  where  a  portion  of  the 
large  intestine  has  become  the  seat  of  disease.  Blood, 
also,  is  sometimes  found  in  these  dejections,  and  is  to 
be  regarded.  A  little  blood  is  not,  however,  a  serious 
matter;  nor  even  is  an  ounce  or  two,  for  a  single 
time,  a  cause  for  alarm.  It  is  bad  when  most,  or  all, 
the  stools  are  colored  by  blood,  and  the  remaining  part 
consists  only  of  mucus,  or  of  slimy  matter,  derived 
from  a  diseased  surface,  while  the  faeces  are  kept 
back.  In  other  words,  it  is  bad  when  the  cholera 
passes  into  dysentery.  I  will  add  that  pus,  which 
you  often  see  in  dysentery,  may  also  occur  in  the 
dejections  of  dysenteric  cholera. 

It  has  long  been  remarked  that  those  alvine  dis- 
charges are  bad,  which  are  pure  or  sincere^  as  they 
have  been  called.  By  pure,  in  this  case,  it  is  meant 
that  the  discharge  consists  of  one  material  alone ;  such 
as  bile,  or  mucus,  or  watery  fluid,  or  blood.  A  dis- 
charge, which  consists  of  two  distinct  portions,  one 
part  of  bile  or  mucus  alone,  and  another  part  of  im- 
perfect faeces,  is  worse  than  when  the  constituents  are 
duly  mixed  together.  I  mentioned  above  that  it  was 
proper  to  regard  the  order  of  the  discharges.     Under 


140 


this  head  I  will  remark,  it  is  favorable  if,  after  a  quiet 
night,  the  patient  has  one  or  two  copious  discharges  in 
the  morning,  although  these  be  followed  by  frequent 
small  dejections  of  a  bad  character.  Observe  that  in 
this  case  the  bowels  have  performed  their  office ;  they 
have  carried  through  the  faecal  mass,  with  more  or 
less  of  morbid  matter.  By  this  they  are  relieved,  at 
the  same  time  that  they  have  shown  vigor.  If,  after 
this  effort,  they  be  irritated,  it  is  of  much  less  impor- 
tance, than  when  they  labor  and  cannot  carry  forward 
their  contents.  I  do  not  wish  to  speak  now  of  the 
treatment ;  but,  to  avoid  describing  this  state  of  things 
again,  I  will  say  that  this  is  the  best  moment,  after 
the  large  evacuations,  for  the  use  of  opium ;  then  the 
opium  is  best  borne,  and,  while  it  gives  rest  to  the 
organs,  it  does  not  aggravate  the  evil  by  retaining  the 
faeces.  Let  me  add  here,  that  it  is  favorable  when 
the  discharges  are  less  frequent,  or  cease  entirely  in 
the  night-time,  corresponding  to  the  course  of  things 
in  health. 

It  is  a  bad  case  when  the  discharges  run  away  in- 
voluntarily, the  child  looking  as  if  unaware  of  the 
occurrence,  and  with  a  sunken  countenance.  If,  with 
this,  the  appetite  is  quite  gone ;  if  there  is  disgust  for 
food,  and  even  for  drink ;  if  the  skin  be  dry,  and  the 
tongue  also,   the  abdomen  distended   by  flatus,  the 


ON   CHOLERA  INFANTUM,    ETC.  141 

pulse  and  the  respiration  showing  great  weakness,  the 
patient  rousing  only  occasionally  with  a  shriek,  or 
perhaps  rolling  the  head  from  one  side  to  the  other 
very  frequently,  or  tossing  it  rather  than  rolling  it ; 
under  these  distressing  circumstances  you  can  scarcely 
hope  for  a  recovery.  But  do  not  despair  entirely. 
In  this  disease,  though  these  and  other  bad  symptoms 
have  accumulated,  recovery  may  take  place.  With  a 
mother  who  cannot  give  up  while  life  continues,  or  a 
faithful  nurse,  to  watch  the  patient,  you  may  see  it 
rise  again  from  the  very  brink  of  the  grave. 

I  hope  I  have  said  enough  to  aid  you  in  understand- 
ing this  disease.  I  think  that  you  must  encounter  it 
at  times,  though  I  believe  that  it  is  vastly  less  common 
now  than  formerly,  when  I  had  most  to  do  with  young 
children.  In  this  city,  the  errors  which  lead  to 
cholera  infantum  are  now  much  better  understood,  and 
are  avoided.  There  is  more  care  as  to  diet,  and  very 
many  children  are  carried  to  the  country  in  the  dog- 
days.  I  will  not  enlarge  on  various  points,  which  are 
less  essential,  but  will  proceed  to  speak  briefly  of  the 
treatment.  ^ 

In  the  acute  attacks  of  cholera  infantum,  the  first 
object  is  the  dislodgment  of  ofiending  materials  from 
the  alimentary  canal.  In  most  cases  the  spontaneous 
efforts  suffice  to  clear  the  stomach.     But,  occasionally, 


142  ON   CHOLERA  INFANTUM,    ETC. 

it  is  evident  that  these  efforts  fail  to  remove  a  load, 
which  the  patient  has,  imprudently,  been  permitted  to 
take  into  the  stomach.  Then  small  doses  of  ipecacuanha 
may  be  given  with  benefit,  till  the  burden  is  thrown 
off.  Two  to  four  grains  for  a  dose  will  usually  suffice. 
Much  more  frequently  the  efforts  of  the  bowels  are 
not  successful  in  carrying  off  their  contents,  and  the 
stomach  is,  at  the  same  time,  so  irritable  as  not  easily 
to  retain  medicine.  Then  calomel  is  the  great  rem- 
edy. Whatever  objections  theoretical  men  may  make 
to  the  use  of  so  potent  a  drug  for  a  tender  infant,  few 
practical  men,  after  having  tried  it,  are  willing  to 
treat  this  disease  without  this  article.  It  is  not  offen- 
sive to  the  taste  ;  it  can  be  retained  when  scarce  any 
other  medicine  can  be ;  and,  if  vomiting  follows  a  dose 
of  it,  the  stomach  becomes  less  irritable,  so  that  a 
way  is  open  for  other  medicines,  or  for  nourishment. 
By  its  operation  the  bowels  are  disburdened  of  their 
load  with  benefit.  But  it  is  a  medicine  which  is  slow 
in  its  operation,  and  castor  oil  may  be  used  after  it 
with  advantage ;  or  a  few  grains  of  jalap  may  bo 
given,  if  the  oil  is  offensive  to  the  stomach.  When 
the  bowels  are  unburdened,  if  the  diarrhoea  does  not 
subside,  it  may  be  arrested  by  opiates.  Erom  three 
to  five  drops  of  the  tincture  of  opium  may  be  given, 
and  the  dose  may  be  repeated  in  eight  or  twelve 


ON   CHOLERA   INFANTUM,    ETC.  148 

hours.  Larger  doses  are  often  requisite ;  but  this 
article  should  be  used  very  watchfully  in  a  new  sub- 
ject, until  its  ability  to  bear  it  is  ascertained.  There 
are  instances  —  very  rare  ones  —  in  which  young  chil- 
dren are  overcome  by  a  very  small  quantity  of  opium. 
I  believe,  upon  the  testimony  of  others,  that  a  child, 
a  year  old,  has  been  killed  by  eight  drops  of  the  tinc- 
ture of  opium.  I  have  known  an  instance  of  one,  two 
years  old,  killed  by  a  dose  of  this  tincture,  given  by  a 
nurse,  under  the  belief  that  it  was  elixir  asthmatic^ 
in  the  dose  of  thirteen  drops.  Such  instances  should 
teach  caution ;  but  in  many  cases  much  larger  doses 
are  required ;  and  such  may  be  given  when  cautious 
trials  have  shown  that  smaller  ones  are  unavailing. 

In  the  acute  and  violent  attacks,  after  the  evacua- 
tions, and  the  administration  of  opiates  sufficient  to 
arrest  the  discharges,  our  reliance  must  be  on  caution 
in  the  use  of  food.  The  human  milk  is  the  best ;  but 
even  that  must  be  given  in  very  small  quantities,  till 
the  stomach  gets  well  quieted.  From  time  to  time 
opiates  may  be  needed  on  account  of  the  diarrhoea.  If 
possible,  however,  these  must  be  reserved  for  the 
nigtit,  and  in  the  day-time  the  bowels  should  be  al- 
lowed a  chance  to  clear  themselves.  Among  children, 
as  among  adults,  we  find  some  on  whom  opiates  do 
not  act  kindly ;  not  producing  quiet  rest,  and  leaving 


144  ON    CHOLERA   INFANTUM,    ETC. 

nausea  and  prostration,  as  consequences,  after  ten  or 
twelve  hours.  In  such  cases  we  are  sometimes  obliged 
to  give  up  this  excellent  medicine,  for  which  we  have 
not  any  good  substitute. 

In  all  cases,  as  soon  as  possible,  we  must  omit  med- 
icines, and  endeavor,  bj  great  care  in  diet  and  regimen, 
to  prevent  a  recurrence  of  the  disease.  If  the  gums 
are  irritated  by  an  advancing  tooth,  they  must  be 
carefully  divided  down  to  the  tooth.  The  good  effect 
of  this  practice  is  doubted  by  those  only  who  do  not 
try  it.  The  requisite  diet  has  been  sufficiently  dis- 
cussed already.  When  the  vigor  of  the  patient  will 
at  all  permit,  he  should  be  carried  freely  into  the 
open  air.  If  it  is  in  a  city,  advise  that  he  shall  be 
taken  into  the  country.  So  great  is  the  effect  of 
change  of  place,  that  even  a  child  well  situated  in  the 
country,  when  in  a  very  bad  way,  should  be  removed, 
if  it  be  only  a  mile,  to  a  new  place,  and  one  of  a 
different  character.  Experience  justifies  us  in  relying 
on  so  small  a  change  for  some  benefit.  Tonics  may 
be  employed  with  benefit  in  the  dyspeptic  state,  to 
which  teething  children  are  reduced  by  diarrhoea,  or 
cholera  infantum.  Wine,  and  even  spirit,  may  be 
given  to  a  large  amount  to  those  who  are  very  much 
reduced,  and  who  cannot  bear  nourishment  enough  to 
sustain  life.     I  am  hardly  willing  to  state  what  quan- 


ON    CHOLERA   INFANTUM,    ETC.  145 

titles  I  have  sometimes  given,  from  the  fear  that  the 
same  might  be  done  when  unnecessary.  In  every 
instance  we  must  decide,  after  careful  watching  of  the 
patient  before  us,  to  what  extent  the  stimulants,  or,  I 
would  rather  say,  cordials,  should  be  carried.  But 
the  bad  cases  are  almost  entirely  among  children  who 
are  weaned.  In  such,  when  possible,  a  woman  should 
be  found  who  can  press  out  the  milk  from  her  breast, 
and  the  child  should  be  supplied  with  this  best  of  food 
and  of  cordials.  I  feel  vastly  more  sure  that  I  have 
saved  life  in  many  instances  by  resorting  to  this  expe- 
dient, than  that  I  have  ever  saved  it  by  the  use  of 
medicine. 

The  occurrence  of  diseases  during  the  first  period 
of  dentition  is  familiarly  known,  and  attributed  to  the 
irritation  of  the  coming  teeth.  It  is  not  so  well  known 
that  the  appearance  of  the  permanent  teeth,  also,  is 
attended  by  diseases  of  various  kinds.  I  feel  satisfied, 
however,  that  this  is  the  case.  I  cannot  quote  any 
authority  in  support  of  this  opinion ;  but  for  many 
years  I  have  pointed  it  out  to  my  brethren,  and  some 
of  these  have  confirmed  my  observations  by  their  own. 

During  the  second  dentition,  then,  a  liability  to 

disease  may  be  remarked  as  well  as  during  the  first j 

though  not  so  great.     Besides  this  general  liability, 

there  are  certain  morbid  afiections  which  are  in  a  good 

13 


146  ON   CHOLERA   INFANTUM,    ETC. 

measure  peculiar  to  the  period.  But  you  will  not 
understand  me  that  these  are  showing  themselves 
during  the  whole  period  of  the  second  dentition  ;  far 
from  it.  There  are  instances  where  disease  is  pro- 
duced during  the  first  years  of  this  period,  and  some 
also  in  the  very  latest  period  of  it.  I  have  seen  per- 
sons between  twenty  and  thirty  much  afi*ected  by  a 
wisdom  tooth  not  yet  protruded,  and  distinctly  re- 
lieved by  cutting  the  gum.  But  I  think  the  most 
common  period  of  suffering  from  the  second  dentition 
is  from  the  tenth  to  the  thirteenth  year.  The  most 
characteristic  affections  are  wasting  of  flesh  and  nerv- 
ous diseases.  The  boy  loses  his  comeliness,  and  his 
complexion  is  less  clear,  while  emaciation  takes  place 
in  every  part,  though  mostly,  perhaps,  in  the  face. 
The  nervous  symptoms  are  various ;  but  the  most 
common  are  a  change  in  the  temper,  and  a  loss  of 
spirits.  With  these  there  is  some  loss  of  strength. 
The  patient  is  unwilling  to  engage  in  play,  and  soon 
becomes  tired  when  he  does  do  it.  Among  the  distinct 
symptoms  which  are  not  uncommon,  I  may  mention 
pain  in  the  head  and  in  the  eyes.  The  headache  is 
not  commonly  severe,  but  it  is  such  as  inclines  the 
patient  to  keep  still.  The  eyes  are  not  only  painful, 
but  are  often  affected  with  the  morbid  sensibility,  to 
which  those  organs  are  subject.     I  have  known  boys, 


ON   CHOLERA   INFANTUM,    ETC.  147 

truly  anxious  to  pursue  their  studies,  obliged  to  give 
them  up  on  this  account ;  and  these,  not  having  the 
disposition  to  plaj,  will  of  choice  pass  the  day  with 
their  mothers,  and  increase  their  troubles  by  the  want 
of  air  and  exercise.  Nervous  affections  of  a  more 
severe  character  are  sometimes  manifested.  Chorea 
is  noticed  very  often  at  this  period  of  life ;  and,  in 
some  instances,  I  have  known  this  disease  to  appear  in 
the  spring  season  for  two  or  three  years  in  succession. 
Some  children  at  this  same  period  become  very  notional 
and  whimsical,  so  that  they  may  be  regarded  as  insane. 
In  one  instance,  a  boy  about  twelve  years  of  age,  would 
loiter  in  the  house,  keeping  his  slippers  on,  careless  in 
his  attire,  and  almost  refusing  to  go  abroad,  even  into 
a  garden.  All  this  was  entirely  different  from  his 
usual  course  of  life,  which  was  very  orderly.  After 
some  months,  he  was  placed  under  the  care  of  a 
medical  gentleman,  who  received  nervous  and  insane 
patients  into  his  house,  and  under  his  treatment  was 
very  shortly  restored  to  a  sound  state. 

The  remedies,  which  I  have  found  most  useful,  are 
as  follows.  First,  a  relief  from  study,  or  from  regular 
tasks  ;  yet  using  books  so  far  as  they  afford  agreeable 
occupation  or  amusement.  Second,  exercise  in  the 
open  air,  preferring  the  mode  most  agreeable  to  the 
patient ;  and,  in  more  grave  cases,  the  removal  from 


148  ON    CHOLERA   INFANTUM,    ETC. 

town  to  country.  The  lad  above-mentioned,  in  whom 
the  disease  had  amounted  almost  to  insanity,  was  very 
skilfully  managed  in  this  way.  The  physician  first 
took  him  to  ride  with  him  as  an  indulgence ;  and  it 
was  felt  to  be  so  by  the  boy.  Then  he  let  him  drive 
the  horse  occasionally,  and,  finding  he  was  interested 
in  the  horse,  he  allowed  him  to  harness  him.  In 
short,  by  means  of  the  horse,  he  restored  him  to  habits 
of  activity,  while  his  mind  and  feelings  were  engaged ; 
when  soon,  instead  of  moping,  he  became  cheerful,  and 
his  flesh  was  restored.  In  all  cases,  the  stomach  and 
bowels  are  to  be  attended  to,  but  the  trouble  with 
them  is  nothing  compared  with  that  during  the  first 
dentition.  Sometimes  iron  may  be  employed  with 
advantage,  but,  generally,  medicines  are  not  required. 
Those,  who  get  much  enfeebled  during  s.ummer,  may 
employ  sea-^bathing  with  benefit. 

When  I  tell  you  that  the  affections  appertaining  to 
this  period  of  childhood  and  youth  have  not  been 
understood  to  be  connected  with  dentition,  you  may 
ask  what  has  been  thought  of  them  ?  My  reply  is, 
that  in  a  large  proportion  of  cases,  where  troublesome 
symptoms  have  occurred,  the  patients  have  been 
thought  to  have  worms  in  the  intestines.  Since  I 
have  become  acquainted  with  the  affections  above- 
deacribed,  I  have  almost  ceased  to  use  pink-root,  and 


149 


rarious  other  remedies  regarded  as  vermifuges.  I 
will  here  remark,  that,  though  worms  in  the  intestines 
do  sometimes  give  occasion  to  grave  symptoms,  yet 
instances  of  this  sort  are  extremely  rare.  In  some  of 
the  worst  cases  produced  by  the  second  dentition, 
disease  of  the  brain  has  been  suspected,  and,  I  fear, 
suffering  has  been  sometimes  inflicted  upon  patients  by 
this  error  in  diagnosis.  A  low  diet  prescribed  under 
this  misapprehension  must  be  very  injurious. 

I  know  very  well  that  many  sagacious  practitioners 
are  satisfied  as  to  frequent  and  serious  evils  from  worms 
in  the  intestines.  I  am  constrained  to  differ  from  them. 
It  is  very  common  to  find  worms  discharged  by  chil- 
dren and  adults,  who  have  previously  been  in  good 
health.  This  will  happen  sometimes  without  obvious 
cause ;  but  more  commonly  in  consequence  of  any 
fever,  under  which  the  patient  ceases  to  take  the  usual 
nourishment.  I  remember  a  case  of  pneumonia,  as 
distinctly  marked  as  possible,  in  which  lumbrici 
were  discharged.  The  attendant  physician  called  the 
disease  a  worm  fever.  I  have  seen  a  man  confined  in 
consequence  of  a  fracture  of  the  tibia,  in  whom  the 
same  evidence  of  a  worm  fever  showed  itself  A 
medical  gentleman,  forty  years  ago,  invited  me  to 
attend  an  autopsy  of  a  boy  who  had  died  of  worm 
fever.  I  accepted  the  invitation,  and  en  laying  open 
13* 


150  ON    CHOLERA   INFANTUM,    ETC. 

the  abdomen  found  the  cayitj  filled  with  pus,  and  all 
the  other  marks  of  peritonitis.  I  would  not  be  under- 
stood to  say  that  we  do  not  ever  see  inconveniences  from 
worms.  The  ascarides  often  occasion  much  uneasi- 
ness, accompanied  by  itching  about  the  anus.  Other 
worms  also  give  trouble  at  times,  but  not  often  any- 
great  trouble.     Excuse  this  digression. 

While  treating  of  cholera  infantum  I  made  mention 
of  the  disease  known  under  the  popular  name  of  canker 
in  the  mouth.  This  is  a  different  affection  from 
aphthcB  of  the  mouth,  and  I  know  of  no  other  distinct 
name,  w^hich  has  been  given  to  it,  except  that  of 
ulcuscula  oris.  This  name  I  got  from  my  master, 
Dr.  Holyoke. 

Ulcuscula  oris  are  little  ulcers  within  the  mouth, 
on  the  cheeks,  gums,  and  tongue  ;  and  more  rarely  on 
the  fauces.  They  may  occur  at  any  period  of  life, 
and  some  persons  suffer  from  them  throughout  their 
lives,  occasionally.  This  is  among  the  hereditary 
diseases.  At  least,  I  know  one  family,  in  which  it 
showed  itself  in  three  successive  generations.  But 
this,  perhaps,  is  not  just  the  same  disease  as  that 
which  occurs  in  childhood.  I  cannot  point  out  the 
difference  as  to  symptoms,  but  I  know  that  it  does  not 
yield,  in  these  cases,  to  the  same  treatment  which  is 
employed  successfully  in  children.     Also,  in  children, 


ON    CHOLERA   INFANTUM,    ETC.  151 

Ihe  disease  often  assumes  a  violent  and  acute  form, 
and  it  is  even  sometimes  epidemic  under  this  form. 
The  local  affection,  as  jou  commonly  see  it,  consists 
in  small,  superficial,  circular  ulcerations.  On  looking 
into  the  mouth,  you  see  a  circular  white  spot,  sur- 
rounded by  a  red  line.  If,  however,  you  catch  the 
disease  at  its  commencement,  you  will  find  that  it  is  a 
vesicle,  but  the  skin  or  pellicle  is  extremely  thin,  and 
is  very  soon  broken,  leaving  the  circular  ulcer.  In 
severe  cases,  you  find  the  gums  generally,  and  some- 
times portions  of  the  cheeks  swollen,  and  very  red. 
The  tenderness  of  the  ulcuscula  is  great,  especially 
when  the  surrounding  parts  are  inflamed ;  but  the 
degree  of  tenderness  varies  more  than  the  appearance 
to  the  eye ;  so  that  some  patients  will  take  food  into 
the  mouth,  and  manage  it  very  well,  while  others,  the 
disease  not  looking  worse,  will  admit  only  the  most 
bland  liquids.  In  some  instances  I  have  seen  children 
refuse  all  nourishment  except  once,  or  at  most  twice, 
in  the  twenty-four  hours  ;  when,  driven  by  desperation, 
they  would  seize  and  swallow  down  a  cup  of  milk.  I 
had  once  a  memorable  case,  in  which  the  disease  was 
protracted  for  some  days  in  its  severe  form,  and 
where  various  articles  were  offered  in  hopes  to  save 
the  child  from  starvation.  Among  these  articles  was 
some  broiled  meat.     The  child  seized  this,  tore  it  to 


152 


pieces  with  his  little  hands,  like  a  wild  beast,  and  then 
pressed  it  to  his  nose,  snuffing  at  it  with  an  obvious 
gratification,  and  seeming  almost  to  derive  nourishment 
from  the  scent.  This  was  done  for  three  or  four  days, 
more  than  once  a  day,  until  he  was  so  far  restored  aa 
to  be  able  to  take  food  into  his  mouth. 

When  the  ulcuscula  occur  in  an  acute  form  they 
are  attended  by  febrile  symptoms,  which  are  especially 
violent  in  the  night.  In  one  season  both  this  disease 
and  measles  were  epidemic,  and  many  children  had 
both  of  them  in  the  course  of  the  spring.  Among 
these  there  were  several  instances,  in  which  the  fever 
attending  the  sore  mouth  was  more  severe,  than  that 
of  the  measles  in  the  same  subject.  This  sore  mouth 
terminates  favorably  when  not  complicated  with 
cholera  infantum.  But  its  violence  may  be  abated, 
and  I  believe  its  duration  may  be  shortened,  by  treat- 
ment, if  this  be  employed  early.  Calomel  should  be 
given  in  doses  of  three  to  five  grains  with  the  same 
quantity  of  jalap,  and  the  dose  may  be  repeated  after 
two  days.  Meanwhile,  an  astringent  gargle,  or 
mouth-wash  should  be  used  every  two  hours  during 
the  day-time.  I  prefer  a  solution  of  sulphate  of 
zinc  to  any  other  article  for  this  purpose.  I  direct 
ten  or  twelve  grains  of  the  sulphate  to  be  dissolved  in 
four  ounces  of  rose-water.    There  is  often  a  difficulty 


153 


In  \ising  any  mouth-wash  for  children.  I  have  been 
in  the  habit  of  doing  it  in  this  manner  :  take  a  tea- 
spoon and  fill  it  nearly  full ;  then  watch  a  chance  for 
introducing  this  into  the  mouth,  and  throw  it  on  one 
side.  If  the  liquid  is  placed  on  the  tongue,  the  child 
can  easily  spit  it  out,  or  swallow  it,  not  allowing  the 
liquid  to  extend  over  the  mouth.  If  it  be  thrown  on 
one  side  of  the  mouth,  or  under  the  tongue  when  this 
is  Hfted  up,  the  child  will  make  an  effort  to  bring  it 
on  the  tongue  in  order  to  spit  it  out.  In  doing  this 
he  will  spread  it  over  the  mouth,  so  that  it  will  reach 
all  the  parts  affected. 


LETTER  X. 

ON    ABSCESS    IN    THE    TONSILS,    ELONGATED    UVULA, 
BRONCHITIS   AND    PNEUMONITIS,  RHEU- 
MATISM  AND    GOUT. 

Before  passing  to  the  organs  of  respiration,  there 
are  two  diseases  about  the  fauces,  on  each  of  which 
I  have  a  word  to  saj.  The  first  is  Abscess  in  the 
Tonsils,  This  disease  you  will  meet  with  not  unfre- 
quently ;  and  you  will  find  that  most  persons,  who 
have  it  once,  will  have  it  again  and  again.  At  first 
the  patient  feels  a  soreness  about  the  throat,  attended 
with  a  difficulty  in  deglutition.  So  far,  it  may  be 
some  other  afiection  of  the  fauces  :  but  some  of  those, 
who  are  subject  to  it,  think  they  can  distinguish  it  by 
a  peculiar  sensation,  a  stinging,  or  something  else, 
from  any  other  disease.  If  examined  at  this  period, 
there  will  be  found  an  enlargement  of  one  of  the  ton- 
sils, such  as  to  press  forward  the  anterior  pillar  of  the 
palate.  In  two  or  three  days  this  tonsil  is  found  to 
be  tense  and  enlarged,  with  a  shining  surface.     The 


ABSCESS   IN   THE   TONSILS,    ETC.  155 

pain  increases  from  day  to  day,  as  does  the  difficulty 
of  swallowing,  so  that  at  last  the  patient  will  avoid 
swallowing  as  much  as  possible.  Accompanying  these 
symptoms  is  a  peculiar  difficulty  of  speech.  The  voice 
sounds  as  if  the  patient  had  a  mouthful  of  pudding  just 
stopped  in  the  fauces.  At  this  time  speaking  is  pain- 
ful, as  well  as  swallowing.  This  disease  is  often  dis- 
tressing, causing  the  patient  to  sit  up  a  great  part  of 
the  time,  and  preventing  quiet  sleep.  The  respiration 
is  impeded,  but  not  seriously;  though  apprehensions 
are  sometimes  excited  on  this  score.  At  length  th-e 
abscess  opens,  sometimes  discharging  freely,  and  giv- 
ing sensible  relief  at  once ;  but  not  uncommonly  the 
orifice  is  small,  and  the  relief  comes  on  gradually. 
An  abscess  in  the  tonsils  is  sometimes  spoken  of  as 
dangerous,  and  patients  are,  not  unnaturally,  filled 
with  fears  ;  but  the  danger  is  very  slight,  if  there  be 
any.  I  have  seen  it  very  many  times,  and  have  never 
seen  a  fatal  case.  When  you  see  the  disease  at  an 
early  period,  you  may  very  naturally  think  of  the 
remedies  proper  for  inducing  resolution,  such  as 
leeches  and  vesication.  Now  I  wish  to  express  to 
you  my  conviction  that  in  these  cases  suppuration 
cannot  be  prevented  by  any  treatment.  I  have  noticed 
the  disease  only  to  state  this  as  the  result  of  my  ex- 
perience.    If  you  believe  me,  it  may  save  trouble  to 


156  ABSCESS   IN   THE   TONSILS,    ETC. 

your  patients.  Leeches  and  blisters  only  add  to  the 
affliction,  and  so  do  gargles.  These  cannot  be  prop- 
erly used.  The  parts  are  too  lame  to  permit  it.  The 
only  relief,  which  art  can  give,  is  by  opening  the  ab- 
scess ;  and,  if  this  be  attempted  too  early,  it  is  una- 
vailing. Where  the  abscess  points,  as  it  sometimes 
does,  posteriorly,  it  is  not  easy  to  reach  the  pus  with 
the  lancet. 

I  will  mention  next  the  elongation  of  the  uvula^  a 
morbid  change  which  may  be  seen  very  frequently ; 
oftener  in  the  old  than  the  young.  In  some  instances 
the  uvula  is  very  much  thickened  and  enlarged,  as  well 
as  elongated ;  sometimes  it  is  long  and  pointed ;  but 
this  is  rare.  When  most  diseased,  it  will  not  be  re- 
tracted upon  stretching  the  fauces  open,  as  it  is  in  a 
sound  state.  The  part  itself  does  not  appear  to  suffer ; 
it  is  not  painful,  nor  sore.  It  is,  however,  very  an- 
noying to  the  surrounding  parts ;  especially  to  the 
root  of  the  tongue,  and  to  the  epiglottis.  In  some 
few  instances  it  causes  nausea.  But  the  common  evil 
from  it  is  a  cough,  or  a  hawking,  or  both.  The  cough 
is  ineffectual,  and  is  therefore  repeated  very  often  ; 
hence  the  surrounding  parts  become  irritated  more  or 
less  extensively,  especially  the  larynx.  In  some  per- 
sons the  muscles  of  the  thorax  are  fatigued,  and  are 
made   lame   and   sore   by  the  coughing.     In  a  few 


ABSCESS   IN   THE    TONSILS,    ETC.  157 

instances  you  will  find  the  voice  affected;  there  is 
hoarseness,  and  some  difiicultj  in  speaking.  The 
trouble  from  this  affection  is  much  aggravated  when 
bronchitis  occurs ;  for  then  the  cough  is  much  more 
frequent  and  distressing  than  would  arise  from  the 
bronchitis  alone.  This  disease  often  continues  for 
years  without  being  suspected,  and  is  always  to  be 
looked  for  in  old  men,  who  have  winter  coughs.  The 
plain  remedy  is  the  amputation  of  the  uvula.  This 
gives  relief ;  sometimes  strongly  marked,  at  once ; 
but  the  surrounding  parts,  which  have  been  long  sub- 
ject to  irritation  from  the  vain  coughing,  may  require 
time  for  their  recovery ;  so  that,  in  most  cases,  the 
full  relief  is  not  immediate.  If  bronchitis  exists 
at  the  time,  the  relief  must  necessarily  be  partial, 
though  ultimately  the  bronchitis  is  terminated  in  a 
shorter  time  than  it  would  otherwise  be. 

Though  I  am  not  a  surgeon,  I  have  a  word  to  say 
upon  this  operation.  The  uvula  should  not  be  cut  off 
at  its  root.  It  is  sufficient  to  remove  from  one  half  to 
two  thirds  of  it,  according  to  its  length.  In  all  cases, 
the  wounded  parts  are  sore  for  a  few  days,  so  as  to  be 
irritated  by  a  hot  liquid,  by  an  acid,  or  by  pepper. 
But  when  the  uvula  is  cut  off  at  its  root,  the  subse- 
quent evil  is  much  greater ;  for,  in  this  case,  when- 
ever the  soft  palate  is  brought  into  play,  the  wound  is 
14 


158  ABSCESS  IN   THE   TONSILS,    ETC. 

stretched  J  the  raw  surface  is  irritated,  and  thus  the 
healing  is  protracted.  But  the  wound  of  the  uvula, 
when  cut  midwaj,  does  not  suffer  in  this  manner,  and, 
like  other  wounds  within  or  about  the  mouth,  will 
commonly  heal  in  a  short  time. 

I  now  proceed  to  diseases  in  the  organs  of  respi- 
ration ;  but  I  shall  not  treat  of  all  of  them ;  and  not 
fully  nor  exactly  of  any ;  for,  as  in  the  preceding  let- 
ters, my  only  object  in  describing  diseases  is  to  make 
it  sure  that  you  shall  know  what  I  am  dealing  with. 

First,  of  catarrh,  or  bronchitis  ;  terms,  which,  at 
the  present  day,  are  nearly  synonymous.  The  patient 
with  catarrh  tells  you  he  has  a  cold,  and  he  thinks 
that  is  all  you  need  to  know.  In  calling  the  disease 
a  cold,  he  refers  to  its  remote  cause,  or  what  he  con- 
siders so.  But  he  would  also  tell  you  he  had  taken 
cold  in  various  other  cases ;  if,  for  instance,  he  is 
aifected  with  ophthalmia,  or  rheumatism;  and,  per- 
haps, if  he  has  a  diarrhoea.  Even  on  the  first  days 
of  typhoid  fever  the  patient  will  talk  of  his  cold. 
Likewise,  patients  affected  with  chronic  diseases  very 
frequently  speak  of  an  aggravation  of  their  symp- 
toms, in  consequence  of  a  cold.  When,  therefore,  a 
patient  says  he  has  taken  a  cold,  it  is  necessary  to 
ascertain  the  symptoms  and  the  order  of  their  occur- 
rence.    In  going  through  this  scrutiny,  I  think  it  is 


159 


of  no  small  use  to  make  the  patient  perceive  just  how 
the  evil  from  cold,  as  a  cause,  has  been  brought  about. 
From  not  attending  to  this  point,  patients  and  their 
friends  are  led  to  believe  that  an  exposure  to  cold 
water  and  to  cold  air  is  always  attended  with  some 
danger,  and  then  they  are  led  into  habits  of  precau- 
tion, under  which  the  liability  to  disease  is  greatly 
increased.  One  who  has  been  in  active  exercise,  and 
especially  if  much  fatigued,  and  then  stands  still  in  a 
cold  atmosphere,  or  goes  into  a  cold  cellar,  or  lies 
down  on  the  damp  grass,  or  sits  in  a  draught  of  wind, 
or  leaves  off  an  accustomed  garment,  is  very  apt  to 
have  a  catarrh,  or  some  other  disease,  which  may  be 
fairly  attributed  to  "taking  cold."  This  comes  from 
the  sudden  reduction  of  temperature  on  the  surface.  I 
I  shall  not  stop  to  inquire  how  this  affection  of  the 
surface  operates  in  bringing  on  a  catarrh,  or  a  rheu- 
matism. And  I  need  not  say  that  there  are  other 
ways,  besides  those  enumerated,  in  which  you  may 
take  cold.  A  mere  exposure  to  a  cold  atmosphere 
does  not  necessarily  make  one  take  cold,  even  when 
exposed  after  being  heated.  The  evil  effects  depend 
very  much  on  the  ordinary  habits  of  the  subject  as  to 
exposure.  If  you  pass  your  time  mostly  in  the  house, 
and  never  move  abroad  without  a  great  abundance  of 
warm  clothing,  and  keep  yourself  over-heated  much 


160 


of  the  time,  the  slightest  exposure  to  a  change  of  tem- 
perature will  give  you  a  cold.  If  such  be  your  case, 
you  should  take  measures  to  harden  yourself,  as  it  is 
termed.  To  this  end  you  may  be  directed  to  use  a 
cold  bath  every  day.  This  is  good  advice.  But,  if 
you  do  no  more,  the  gain  will  be  very  moderate. 
This  remedy,  operating  only  a  few  minutes  in  a  day, 
will  have  very  little  influence  unless  your  habits  be 
changed  in  other  respects.  The  most  important  change, 
in  such  a  case,  is  to  go  abroad  daily  and  get  exercise 
in  the  open  air,  whatever  the  weather  may  be.  This 
cannot  be  done  fully  at  once ;  the  change  must  be  grad- 
ual. At  the  same  time,  the  habit  of  heavy  clothing 
must  be  gradually  abandoned.  As  near  as  may  be, 
the  clothing  should  be  such  as  you  can  move  under 
with  ease,  and  without  inducing  great  heat.  This  is 
the  advice  to  be  given  to  one  who  is  apt  to  suffer  from 
exposure  to  cold  weather.  There  are  some  persons 
who  seem  incapable  of  being  hardened  to  the  weather 
in  any  way ;  but  they  are  very  rare  exceptions. 

A  catarrh  consists  in  an  inflammation  of  the  mucous 
membrane  of  the  nose,  fauces,  windpipe,  and  its  subdi- 
visions, the  bronchi.  It  may  commence  in  any  one 
part,  and  be  limited  to  that ;  but  it  very  commonly 
spreads  from  the  part  first  affected.  Usually,  in 
spreading,  it  leaves  this  part  in  a  state  of  recovery 


ABSCESS   IN   THE   TONSILS,    ETC.  161 

while  it  extends  to  the  adjoining  parts,  in  the  same 
manner  as  erysipelas  spreads  on  the  skin.  Most  com- 
monly the  disease  begins  in  the  nose,  and  travels  down 
to  the  larynx,  where  it  causes  a  hoarseness,  and  thence 
it  goes  to  the  bronchi  on  one  side,  or  occasionally  to 
both.  In  the  lungs  its  extent  may  be  greater  or  less. 
When  it  reaches  the  extreme  air-vessels,  especially  if 
it  affects  many  of  them  at  the  same  time,  it  becomes 
a  somewhat  grave  disease.  A  catarrh  is  sometimes 
very  slight  and  limited ;  at  others  severe  and  exten- 
sive. The  constitutional  affection  bears  a  relation  to 
its  severity  and  to  its  extent.  When  the  disease  is  in 
the  bronchi,  it  is  at  the  present  day  called  bronchitis j 
though  this  word  is  used  loosely,  and  is  employed  by 
many  when  the  disease  is  in  the  larynx. 

A  severe  bronchitis  often  receives  the  name  of  in- 
fluenza in  our  community.  But  influenza,  though  it 
commonly  includes  bronchitis,  is  a  different  disease. 
It  is  ushered  in  by  constitutional  symptoms,  chills, 
pains  in  the  head,  back  and  limbs,  as  happens  in  more 
grave  febrile  diseases.  It  is  also  an  epidemic,  and  an 
extensive  epidemic,  spreading  over  a  continent  in  the 
course  of  a  few  months,  or  even  of  a  few  weeks.  It 
is  doubtful  if  this  disease  is  ever  sporadic.  When  the 
great  and  learned  have  a  severe  bronchitis,  there  often 
fs,  among  all  concerned,  a  disposition  to  magnify  the 
14* 


162 


disease,  and  then  it  is  called  an  influenza.  Now,  1 
could  tell  the  reverend  or  the  honorable  gentleman, 
that  when  he  has  the  influenza,  the  chance  is  that  the 
domestics  in  his  kitchen  will  have  it  too.  I  should 
not  make  this  remark  if  I  did  not  believe  that  the 
patient,  who  has  his  malady  thus  exalted  by  a  great 
name,  is  often  led  into  some  unnecessary  evils  by  the 
misnomer. 

When  a  catarrh,  or  bronchitis  is  not  severe,  a  per- 
son, whose  usual  health  is  good,  may  pursue  his  com- 
mon course  of  life.  But  if  severe,  or  if  the  patient 
has  not  a  very  sound  constitution,  some  precautions 
should  be  taken.  For  two  or  three  days,  at  the  com- 
mencement, the  food  should  be  diminished,  and  that 
which  is  most  stimulant  should  be  avoided.  If  there 
be  chilliness,  well  marked,  a  slender  person  should 
keep  the  house  for  one  or  two  days.  But  this  should 
not  be  done  for  a  slight  cause,  as  if  it  was  the  safer 
course  at  any  rate.-  There  is  danger  in  keeping  close 
upon  every  slight  occasion,  for  thereby  the  system  is 
made  more  susceptible ;  and  then  slight  exposure  will 
aggravate  the  disease,  or  induce  disease  anew. 

Medicinal  remedies  are  not  often  advisable,  even  in 
bronchitis,  except  when  a  cough  becomes  troublesome, 
preventing  sleep,  or  causing  soreness  or  lameness  in 
the  breast.     Then  opium,  combined  with  ipecac,  or 


163 


some  preparation  of  antimony,  is  useful.  This  should 
be  taKen  at  night ;  and  as  the  opium  will  commonly 
occasion  costiveness.  it  is  well  to  counteract  this  by 
adding  some  cathartic  in  a  small  dose.  For  this  pur- 
pose two  or  three  grains  of  comjwund  extract  of 
colocynth^  or  as  much  aloes ^  will  often  suffice.  A 
si^th  of  a  grain  of  tartarized  antimony,  and  double 
that  quantity  of  opium,  is  usually  sufficient,  as  the 
night  dose  for  an  adult.  Two  or  three  grains  of 
squills  may  be  advantageously  added  to  this  dose, 
when  the  expectoration  is  scanty  and  difficult.  In 
bad  cases  it  is  useful  to  give  one  to  three  grains  of 
calomel,  instead  of  the  colocynth,  for  one  or  two 
nights. 

For  an  adult,  previously  healthy,  who  is  affected 
with  bronchitis  and  is  anxious  to  throw  off  the  disease 
at  once,  even  with  some  inconvenience,  a  more  active 
practice  may  be  used.  If  not  always  successful,  it 
will  commonly  be  found  so,  when  employed  in  the  first 
week  of  a  bronchitis.  The  following  is  the  dose  which 
I  have  employed  for  this  purpose;  in  some  cases 
giving  half  of  it  only.     It  should  be  taken  at  bed-time. 

R.  Antimon.  tartar g^-  j- 

Pulv.  opii g^-  j- 

Hydr.  submur gi*-  x. 

Mucilag.  gum  acac.  qs.  m.  f.  pil.  No.  iij. 


164  ABSCESS   IN   THE   TONSILS,   ETC. 

Such  a  dose  should  never  be  given  to  a  scrofulous 
or  tubercular  subject,  nor  to  one  approaching  old  age. 
nor  to  any  one  in  tender  health.  Usually  much 
milder  articles  serve  to  mitigate  the  symptoms  of 
bronchitis.  When  there  are  no  strong  inflammatory 
symptoms,  the  tincture  of  tolu  is  very  useful ;  that 
may  be  sweetened  by  the  syrups  of  tolu  and  of  squills. 
Half  a  drachm  of  each  may  be  given  three  or  four 
times  a  day,  and  double  the  dose  at  bed-time.  A  little 
opiate  should  be  added  when  the  cough  is  very  urgent. 
In  chronic  bronchitis  the  same  is  valuable  among  the 
mild  remedies.  For  young  children,  under  a  trouble- 
some bronchitis,  I  employ  the  following:  Take  of 
either  almond  or  olive  oil,  of  syrup  of  squills,  of  any 
agreeable  syrup,  and  of  mucilage  of  gum  acacia,  equal 
parts,  and  mix  them.  Of  this  mixture  a  teaspoonful 
may  be  given  to  a  child  at  two  years  of  age ;  a  little 
less  if  younger,  and  increased  if  older,  so  as  to  double 
the  dose  to  one  in  the  sixth  year.  This  may  be  given 
from  three  to  six  times  in  the  twenty-four  hours. 
Sometimes  a  little  opiate  must  be  added  at  night  to 
appease  an  urgent  cough.  The  diet  at  first  should  be 
simple  in  kind  and  moderate  in  quantity ;  but,  when 
the  first  violence  of  the  disease  has  subsided,  the  usual 
diet  may  be  allowed. 

I  have  very  little  to  say  on  pneumonitis.     I  be- 


ABSCESS   IN   THE  TONSILS,    ETC.  165 

lieve  that  this  disease  is  very  rarely  fatal  to  healthy 
adults,  except  during  an  epidemic  of  a  peculiarly  bad 
character,  or  unless  it  affects  both  lungs.  If  the  pa- 
tient have  tubercles  in  the  lungs,  or  a  cancer,  or  other 
malignant  affection,  or  if  worn  down  by  any  other  dis- 
ease, or  by  intemperance,  the  danger  is  very  consider- 
able. The  same  remarks  may  be  made  in  regard  to 
pleuritis  and  pericarditis,  when  not  complicated. 

In  young  children  the  disease  is  attended  with  more 
danger,  than  in  adults.  The  same  is  true,  in  some 
measure,  as  to  persons  past  seventy  years  of  age.  Yet 
in  these,  and  even  in  those  past  eighty,  if  the  consti- 
tution be  not  very  slender,  and  if  the  habits  of  life 
have  been  good,  almost  all  recover,  provided  one  lung 
only  be  affected. 

The  common  practice  has  been  to  take  blood  from 
the  arm  in  pneumonitis.  I  am  satisfied  that  this  is 
wise,  if  the  patient  is  vigorous  and  not  very  old,  pro- 
vided it  be  done  on  the  first  or  second  day  of  the 
disease.  Even  on  the  third  day,  in  a  strong  man,  it 
is  a  good  practice ;  but  later  than  this  I  believe  it  is 
useless  at  least,  and  that  it  is  sometimes  injurious. 

M.  Louis,  of  Paris,  has  shown  that  the  disease  is 
not  arrested,  nor  materially  shortened,  by  bleeding, 
as  he  has  seen  it  practised ;  but  I  believe  that  all  the 
cases  lie  has  brought  forward  had  arrived  at,  or  passed 


166 


the  third  day  of  the  disease  before  the  bleeding  had 
taken  place.  An  examination  of  the  cases  at  the 
Massachusetts  General  Hospital  confirmed  the  opinion 
advanced  by  M.  Louis. 

I  have  said  that  this  disease  is  attended  with  more 
danger  in  young  children  than  in  adults.  In  such 
young  subjects,  when  vigorous,  I  have  thought  bleed- 
ing, within  the  first  forty-eight  hours,  decidedly  bene- 
ficial ;  lightening  the  disease,  if  not  shortening  it.  In 
young  children  it  is  not  easy  to  find  any  good  vein  for 
the  operation,  except  the  external  jugular.  It  is  not 
difficult  to  open  this  vein.  I  have  done  it  many  times 
for  this  and  other  diseases.  I  never  lamented  that  I 
had  done  it ;  I  have  lamented  very  much  in  some 
instances  that  I  had  not  done  it. 

Whether  bleeding  has,  or  has  not  been  employed,  I 
believe  that  the  free  use  of  antimonials  in  the  first  week 
of  pneumonia  is  beneficial.  They  diminish  the  violence 
of  the  disease  at  least.  But  there  a,re  many  delicate 
subjects  who  do  not  bear  this  article  well.  In  regard 
to  mercurials  I  have  not  so  favorable  an  opinion.  I 
have  seen  them  tried  fully.  They  were  very  univer- 
sally employed  in  this  vicinity  when  I  was  a  pupil 
and  many  years  afterwards.  They  were  not  at  all 
used  in  England  when  I  was  there,  in  1799  and  1800. 
They  were  first  introduced  in  inflammatory  complaints 


167 


at  a  later  period,  and  have  been  in  great  favor  there 
for  twenty  or  thirty  years.  I  think  that  they  will  not 
remain  in  favor  fifty  years  hence,  there  or  elsewhere, 
for  the  relief  of  simple  inflammation. 

In  mild  cases  of  pneumonitis,  and  in  very  feeble 
subjects,  it  seems  to  me  most  safe  to  avoid  all  active 
treatment.  In  all  cases  opiates  are  sometimes  useful 
to  prevent  urgent  coughing ;  but  they  should  be  used 
very  moderately,  and  not  in  the  early  stage  of  the  dis- 
ease. When  the  disease  continues,  without  much 
abatement,  towards  the  end  of  the  second  week  diar- 
rhoea sometimes  occurs.  This  should  not  be  checked 
suddenly,  for  it  affords  relief  I  think  I  never  saw 
this  except  when  the  disease  was  in  the  right  side ; 
and  I  have  supposed  that  the  liver  was  first  congested 
and  then  a  great  secretion  of  bile  was  induced. 

As  this  letter  is  not  very  long,  I  will  add  a  few 
words  in  respect  to  rheumatism  and  gout,  and  only  a 
few. 

Rheumatism  is  a  very  large  box,  and  contains  quite 
a  variety  of  things ;  and  these-  things  do  not  all  agree, 
either  as  to  their  material,  or  their  form.  This  is  con- 
ceded at  once  as  to  the  acute  and  chronic.  The  acute 
disease,  known  as  rheumatic  fever ^  has  a  pretty  dis- 
tinct character ;  its  form  and  pressure  are  such  that  a 
man,  who  has  once  endured  them,  does  not  easily  forget 


168 


them.  If  any  good  is  to  be  done  in  this  disease,  it 
must  be  at  the  very  beginning ;  just  as  I  have  endeav-. 
ored  to  show  about  all  diseases,  especially  such  as 
are  acute.  The  chance  in  this  disease  is  not  so  good 
as  in  some  others.  Free  evacuations  and  low  diet 
from  the  first  are,  I  think,  certainly  useful,  though 
they  do  not  jugulate  the  disease.  But  there  is  a 
natural  relief  in  two  or  three  weeks,  and  then  patient 
and  doctor  are  too  apt  to  think  the  disease  is  going 
away.  Not  so  ;  if  ever,  very  rarely.  At  this  stage 
medicine  will  not  do  much,  if  anything ;  but  care  may 
do  much.  Not  the  care  which  keeps  a  man  smothered 
up,  such  as  to  increase  the  excessive  perspiration 
which  belongs  to  the  disease.  Let  the  patient  be  as 
lightly  covered  as  is  consistent  with  his  present  com- 
fort ;  that  will  be  enough.  But  the  care  must  be  in 
avoiding  any  great  effort  of  body  or  mind,  in  maintain- 
ing calmness  and  tranquillity,  and  in  moderate  diet. 
Give  enough  milk  and  bread,  or  some  other  vegetable 
article,  to  support  the  patient;  but  withhold  animal  food. 
If  the  disease  is  not  checked  at  the  beginning,  avoid  all 
strong  medicines,  except  opium  for  severe  pain.  Keep 
the  bowels  open,  and  be  watchful  as  to  diet.  If  any- 
thing has  been  useful  in  my  hands  after  the  first  few 
days  of  the  disease^  it  is  the  sulphate  of  quinia. 
This  article,  taken  as  freely  as  it  is  for  intermittent 


ABSCESS  IN   THE   TONSILS,    ETC.  169 

fever,  appears  sometimes  to  arrest  the  disease.  It  is 
not,  however,  as  certain  as  was  believed  by  Dr.  Hay- 
garth  in  respect  to  the  cinchona  itself. 

Next,  —  the  local  rheumatism^  from  which  a  large 
part  of  mankind  suffer  more  or  less  frequently,  about 
the  shoulders,  or  loins,  or  elsewhere,  may,  I  believe, 
be  stopped  in  all  cases,  —  at  the  heginning  ;  and  this 
by  the  old  remedy,  flannel,  red,  blue,  or  white.  Two 
things  are  important ;  first,  that  the  flannel  be  applied 
at  once,  when  the  pain  comes ;  not  by  and  by.  It 
should  be  applied  within  the  first  six  hours  ;  and  it  is 
better  to  apply  it  the  first  hour.  On  the  second  day 
it  does  very  little  good.  Second,  the  flannel  should 
be  new  and  thick,  or  doubled,  and  there  should  be 
enough  of  it  to  extend  much  beyond  the  region 
affected.  It  should  be  kept  on  until  the  pain  has  been 
quite  gone  for  twenty-four  hours.  Meanwhile,  one 
who  is  accustomed  to  cold  bathing  may  continue  this, 
taking  care  to  use  extra  friction  after  it.  In  some 
instances  of  lumbago  particularly,  I  have  seen  decided 
benefit  from  applying  a  solid  lump  of  ice  to  the  part, 
and  holding  it  there  as  long  as  the  patient  can  make 
up  his  mind  to  bear  it.  But  this  should  not  be  done 
except  to  a  man  in  good  health  and  of  good  vigor 

Last,  there  is  an  affection,  called  rheumatism, 
which  begins  hi  the  small  joints^  in  the  hands  and 
15 


170  ABSCESS   IN   THE   TONSILS,    ETC. 

feet ;  first  in  the  hands  most  commonly.^  It  differs 
from  goutj  inasmuch  as  it  begins  slightly,  and  increases 
gradually,  extending  from  part  to  part.  Probably  the 
patient  does  not  apply  for  medical  aid  until  he  has  had 
it  long  enough  for  two  or  three  fits  of  the  gout.  By 
degrees  the  disease  spreads  to  the  large  joints ;  but 
whereas  acute  rheumatism  is  getting  well  in  one  part, 
while  it  is  increasing  in  another,  this  disease  seldom 
leaves  a  part  entirely  on  which  it  has  once  fixed  itself 
It  is  a  chronic  disease,  not  affecting  the  system  very 
sensibly  at  first,  but  gradually  bringing  on  a  cachexy. 
I  do  not  know  that  any  writer  has  noticed  this  disease, 
distinguished  by  the  slow  beginning  in  the  small  joints 
and  gradually  extending ;  but  men  of  experience 
cannot  have  failed  to  see  it,  though  it  is  not  an  every- 
day malady. 

There  is  a  very  bad  part  of  this  story ;  bad  for  me. 
I  do  not  know  of  any  remedy  for  it.  The  patients 
live  under  it  twenty  and  thirty  years,  and  of  course 
they  try  all  sorts  of  remedies,  but  they  do  not  recover. 
Such,  at  least,  is  my  experience.  It  is  to  guard 
against  inflicting  useless  suffering  on  the  patients  that 
I  have  made  this  statement.  I  beg  my  brethren  to  be 
tender  with  such  persons.  The  humoralists  of  the 
present  day  have  turned  their  attention  to  rheumatism. 
I  hope  that  they  will  continue  to  study  it.     The  dis 


ABSCESS   IN   THE   TONSILS,    ETC.  171 

ease  I  have  just  referred  to,  obviously  different  from 
any  other  thing  called  rheumatism,  is  most  especially 
worthy  the  study  of  men  truly  scientific,  and  willing 
to  he  patient  in  their  investigations. 

Now  of  gout.  I  shall  not  say  a  word  respecting 
the  disease;  I  wish  only  to  consider  the  treatment. 
And  my  only  wish  on  that  score  is  to  add  my  testi- 
mony to  that  of  many  of  the  highest  authority,  in 
respect  to  colchicum.  That  remarkable  article  is 
sometimes  found  useful  at  any  period  of  gout ;  but  it 
is  comparatively  of  little  use  except  in  the  very  outset. 
The  great  point  to  be  ascertained,  in  regard  to  each 
individual  patient,  is  the  dose  he  requires.  This  should 
be  enough  to  act  on  the  bowels  quite  freely,  without 
being  so  much  as  to  cause  nausea.  For  most  persons 
such  a  dose  may  be  found.  If  some,  having  irritable 
stomachs,  cannot  bear  without  nausea  sufficient  for  the 
purpose,  then  give  what  the  stomach  will  bear  with 
ease,  and  repeat  the  same  in  six  or  eight  hours.  It 
may  sometimes  be  necessary  to  use  some  cathartic  in 
addition.  In  most  instances  the  fit  dose  for  any  indi- 
vidual may  be  found ;  that  settled,  let  him  take  his 
dose  as  soon  as  he  feels  the  gout.  Let  him  not,  on 
any  account,  wait  longer  than  six  hours,  after  the  first 
sign  of  gout,  before  he  takes  his  dose.  Then,  in  all 
probability,  his  disease  will  vanish  within  twenty-four 


172 


ETC. 


hours.  He  may  take  a  dose  unnecessarily  once  in  ten 
times.  This  is  a  small  loss  for  the  benefits  he  will 
obtain  on  the  whole.  Gout  is  not  so  common  among 
US  as  to  permit  me  to  speak  from  a  large  experience, 
but  I  believe  this  statement  to  be  substantially  correct. 
I  should  feel  less  confidence  in  it,  if  it  did  not  accord 
with  the  opinions  of  the  best  physicians  in  England, 
the  country  where  the  gout  prevails  most  extensively. 


LETTER  XI. 

ON   PHTHISIS   AND   HEMOPTYSIS. 

I  SHALL  now  treat  of  Phthisis  Pulmonalis.  This 
is  a  disease  which  carries  off  a  very  large  proportion 
of  mankind  in  all  climates ;  more,  I  presume,  than 
one  sixth.  I  confine  the  name  to  cases  which  are 
founded  on  tubercles,  as  most  medical  men  do  at  the 
present  day.  Though  almost  uniformly  fatal,  the 
disease  differs  much  in  the  rapidity  of  its  course.  In 
general  terms,  it  is  more  rapid  in  the  young  than  in 
those  much  advanced  in  life.  It  occurs  in  young 
children,  though  not  frequently.  From  eighteen  to 
thirty-six  years  of  age,  men  and  women  are  very  sub- 
ject to  it ;  and  its  course  is  comparatively  rapid,  rarely 
lasting  much  more  than  two  years.  Some  melt  away 
at  once  ;  and  this  happens  even  to  those  who,  at  first, 
are  florid  and  full  of  flesh.  Some  persons  endure  it 
for  ten  and  twenty  years,  and  perhaps  longer.  This 
happens  mostly  in  those  who  are  thirty-five  or  forty 
years  old,  before  the  disease  commences.  Some,  who 
are  not  very  vigorous  in  appearance,  will  fight  every 
15* 


174  ON   PHTHISIS   AND   HEMOPTYSIS. 

inch  of  ground,  even  under  great  sufiering.  It  is  not 
to  the  slender  and  feeble  only  that  it  comes,  but  occa- 
sionally to  large  men,  showing  all  the  usual  marks 
of  vigor.  It  is  a  satisfaction  to  be  able  to  say  that 
phthisis  is  not  always  fatal ;  we  do  see  instances  of 
recovery  from  it. 

I  shall  not  enter  into  the  history  of  the  disease,  but 
shall  point  out  what  I  consider  the  great  principles,  by 
which  to  be  guided  in  the  treatment  of  it.  These 
have  regard  not  only  to  the  part  affected,  but  to  the 
system  at  large.  We  must  endeavor  to  prevent  the 
cachexy,  if  that  has  not  appeared,  or  to  overcome  it 
when  it  has.  To  effect  this  purpose  we  must  not 
rely  on  medicinal  drugs.  We  must  pursue  a  course 
calculated  to  increase  the  general  vigor  of  the  system, 
trusting  to  the  natural  efforts  to  overcome  the  disease, 
if  that  be  possible;  and  we  may  do  this  with  the  more 
confidence,  as  such  a  course  may,  at  least,  prolong 
life,  if  we  cannot  save  it.  To  this  end  we  should 
direct  a  nutritious  diet ;  but  we  must  not  leave  the 
patient  to  judge  what  articles  are  comprehended  in 
such  a  diet.  For  nutrition,  we  must  direct  animal 
food,  millc,  and  the  farinaceous  articles.  These  are 
sufficient  for  that  purpose ;  but  if  they  should  be  used 
alone,  the  functions  of  the  bowels  would  not  be  well 
performed.     In  that  case,  costiveness  would  lead  to 


ON   PHTHISIS   AND   HEMOPTYSIS.  175 

djspepsj,  to  dryness  of  the  mouth,  to  heat  of  the  skin, 
and,  perhaps,  to  trouble  about  the  head,  with  uneasy 
sleep.  So  far,  tljerefore,  as  the  bowels  require  it, 
there  should  be  added  fruit  and  other  articles  of  a 
laxative  character.  Next  to  the  diet,  and  of  all  things 
most  important,  is  exercise  in  the  open  air.  This 
should  be  carried  as  far  as  the  vigor  of  the  patient 
will  permit.  It  should  not  be  done  rashly,  but 
boldly.  If  possible,  the  patient  should  be  made  to 
have  faith  in  it ;  for,  without  this,  he  is  not  likely  to 
pursue  it  as  far  as  he  can^  and  then  he  will  not  derive 
from  it  all  the  benefit  which  it  can  afford.  An  in- 
stance occurred  to  me,  nearly  fifty  years  ago,  which  I 
have  often  related  since,  as  well  calculated  to  produce 
a  proper  faith.  It  confirmed  my  previous  convictions 
on  the  subject.  A  man  presented  himself,  in  the 
month  of  May,  who  lived  in  a  retired  part  of  Maine, 
below  Penobscot  river.  He  had  come  from  his  home, 
with  great  inconvenience,  to  seek  for  medical  aid.  I 
found  that  he  had  the  usual  symptoms  of  phthisis; 
he  had  been  confined  to  his  house  in  January,  at 
which  time  he  sweat  profusely  in  the  night,  was  much 
reduced  in  strength,  and  wretchedly  sick.  He  saw, 
however,  that  he  and  his  family  must  starve,  if  he 
could  not  engage  in  his  usual  winter  employment  of 
cutting  wood.   After  much  reflection  he  went  forth,  on 


176  ON  PHTHISIS  AND   HEMOPTYSIS. 

the  first  of  February,  with  his  axe  on  his  shoulder. 
He  labored  for  half  an  hour,  when  he  was  so  exhausted 
that  he  was  forced  to  lie  down  upon  the  snow.  Thus 
ended  his  first  day's  trial.  He  persevered,  however, 
and  by  degrees  gathered  strength,  so  that  at  the  end 
of  the  season  he  could  do  a  moderate  day's  work. 
This  story  he  told  me  with  many  details,  which  I 
need  not  repeat.  They  were  such  as  to  show  conclu- 
sively that  his  was  a  case  of  phthisis.  Auscultation 
was  then  unknown.  I  told  him  that  his  story  was  a 
very  interesting  one,  and  very  instructive ;  that  he 
had  done  more  for  himself  than  any  drugs  could  do ; 
and  that,  if  his  health  could  be  restored,  it  would  be 
by  continuing  the  course,  on  which  he  had  so  happily 
entered. 

The  mode  of  exercise  should  be  such  as  the  strength 
and  circumstances  of  the  patient  permit.  One  would 
not  have  proposed  such  a  course  as  was  pursued 
by  the  man  from  Maine ;  and  I  presume  that  no 
man  could  have  gone  through  that  course,  who  was 
not  urged  by  necessity.  In  general,  exercise  on  horse- 
back is  to  be  commended.  It  does  not  embarrass  the 
organs  of  respiration,  which  walking  does  in  some 
instances  ;  and  it  does  bring  the  muscles  into  play 
which  driving^  or  riding  on  wheels,  does  not.  Work 
ing  in  a  garden  would  suit  some  persons.     Any  exer- 


ON  PHTHISIS  AND   HEMOPTYSIS.  177 

cise  is  better  than  a  life  of  rest.  I  once  had  a  patient 
who  got  his  living  by  white-washing.  That  is,  he 
passed  his  time  in  washing  the  inside  walls  and  ceil- 
ings of  houses ;  thus  surrounded  by  moisture,  and  in 
rooms  where  it  was  necessary  to  keep  open  windows, 
and  consequently  steady  drafts  of  air  about  him.  He 
was  satisfied  that  he  did  better,  when  he  kept  at  hia 
work,  than  when  he  staid  at  home. 

Besides  the  attention  to  diet  and  exercise,  it  is 
proper  to  enjoin  care  as  to  clothing.  The  skin  should 
be  protected  against  sudden  vicissitudes  of  the  weather, 
by  woollen  garments.  Especial  care  should  be  di- 
rected, during  passive  exercise,  against  the  chilling 
effects  of  the  atmosphere  at  certain  seasons.  Yet  it  is 
proper  that  the  patient  should  abstain  from  such  a 
weight  of  clothing  as  would  be  oppressive.  Regular 
habits  as  to  sleep  should  be  enjoined ;  and  exposure 
abroad  during  the  evening  should  be  forbidden.  But, 
in  the  day-time,  the  patient  should  not  be  kept  within 
doors  by  clouded  skies,  nor  by  east  winds,  nor  by 
slight  falls  of  rain,  or  of  snow.  Even  in  tempestuous 
weather  the  more  hardy  ones  may  drive  out  some- 
what. It  is  well  for  the  patient  to  feel  that  the  risk 
is  in  staying  in  the  house,  and  not  in  going  out  of 
it.  In  all  this,  I  have  had  reference  to  tubercular 
subjects  in  the  earlier  periods  of  disease.     But  a 


178  ON   PHTHISIS   AND   HEMOPTYSIS. 

patient,  with  the  right  spirit,  may  go  abroad  somewhat 
till  the  last  week,  and  even  to  the  last  day  of  life.  If 
any  one  object  to  dragging  out  a  patient,  when  greatly 
reduced  in  strength  and  flesh,  I  agree  with  him ;  I 
would  not  drag  him  out.  But  some  persons  find  the 
open  air  so  necessary  to  their  comfort,  that  they  are 
anxious  to  go  abroad,  though  they  know  that  death  is 
near  at  hand.  I  think  it  right  that  such  should  do 
so ;  they  may  suffer  somewhat  in  doing  it,  but  they 
suffer  in  the  opposite  course.  Contrast  with  such  a 
case  a  patient,  who  passes  the  last  two  or  three  months 
of  life  in  the  bed,  sitting  up,  at  most,  an  hour  or  two 
in  the  day.  In  such  a  one,  the  misery  of  muscular 
weakness,  added  to  the  necessary  evils  of  the  disease, 
is  extremely  great.  One  great  evil  from  a  confine- 
ment in  bed  consists  in  the  bed  sores,  which,  for  weeks 
before  death,  do  not  permit  the  patient  to  find  any 
position,  in  w^hich  he  can  rest  without  great  pain.  It 
is  true  that  inevitable  circumstances  may  prevent  the 
patient  from  the  exercise,  by  which  these  evils  may  be 
averted.  But,  for  the  most  part,  we  may  guard 
against  them,  by  keeping  in  mind  one  physiological 
principle.  In  a  wasting  disease,  like  phthisis,  the 
muscular  strength,  once  lost,  can  seldom  be  regained, 
and  never  in  the  later  stage  of  disease ;  while  the 
muscles,  if  kept  in  daily  use,  will  retain  their  power, 


ON   PHTHISIS   AND    HAEMOPTYSIS.  179 

though  not  unimpaired,  almost  to  the  last  moment 
of  life. 

I  wish  not  to  say  anything  of  medicine  in  this  dis- 
ease, although  much  may  be  done,  in  its  advanced 
stages,  to  mitigate  troublesome  and  distressing  symp- 
toms. For  instance,  to  patients  who  can  bear  it  well 
opium  is  invaluable.  Tonics,  too,  are  occasionally  use- 
ful. But  each  case  must  be  studied  by  itself,  and  the 
juvantia  and  laedentia  must  be  sought  out,  without 
following  any  universal  rules. 

There  is  one  affection  connected  with  phthisis  which 
I  will  treat  of  separately.  This  is  haemoptysis,  or 
spitting  of  blood.  This  is  the  first  symptom,  which 
occurs  in  a  large  proportion  of  consumptive  cases. 
Quite  independently  of  a  knowledge  of  this  fact,  spit- 
ting of  blood  always  creates  alarm  in  the  patient. 
The  stoutest  hearts  quail  under  it.  Some  persons  are 
made  faint  by  the  sight  of  one  drop  of  blood  which 
they  believe  to  come  from  the  lungs.  It  is  thought 
that  there  is  much  present  danger  from  this  hemor- 
rhage ;  but  it  is  not  so.  Patients,  who  are  taken  with 
spitting  of  blood,  sometimes  die  at  once,  or  within  a 
few  days ;  but  these  are  in  an  advanced  stage  of 
phthisis.  These,  I  take  it,  are  cases  in  which  an 
urtery  of  some  magnitude  is  laid  open  in  a  tuberculous 
cavity.     The  blood-vessels  in  the  parietes  of  such  a 


180  ON   PHTHISIS  AND   HEMOPTYSIS. 

cavity  are  secured  bj  a  natural  process,  as  the j  are  in 
the  parietes  of  an  abscess.  But,  in  rare  instances 
some  vessel  so  secured  and  plugged  up  is  opened  by 
an  ulceration,  with  which  the  adhesive  process  within 
the  vessel  has  not  kept  pace.  A  bleeding  from  this 
cause  in  an  advanced  stage  of  the  disease  is,  as  before 
intimated,  sometimes  immediately  fatal. 

Another  case  of  immediate  death,  where  haemoptysis 
exists,  is  that  arising  from  the  rupture  of  an  aneurism 
within  the  thorax.  One  man  with  this  disease,  on 
waking  in  the  morning,  said  to  his  companion  that  he 
felt  remarkably  well.  In  the  next  minute  the  blood 
began  to  issue  from  his  mouth,  and  so  much  poured 
out  as  to  run  across  his  chamber.  The  death  was 
immediate.  There  was  not  any  post  mortem  exam- 
ination in  this  case;  but  the  disease  had  been  distinctly 
shown  during  life.  Another  died  after  having  had 
repeated  bleedings  for  several  successive  days.  In 
this  instance  there  was  found  an  aneurism  of  the  aorta, 
in  which  an  opening  had  occurred  through  its  thick- 
ened parietes,  consisting  mostly  of  coagula.  This 
opening  was  at  first  very  small,  but  at  length  enlarg- 
ing, the  whole  chest  was  inundated. 

I  have  known,  in  my  own  practice,  only  two  in- 
stances in  which  death  has  immediately  followed 
haemoptysis,  except  such  as  would  come  under  the 


ON   PHTHISIS   AND   HEMOPTYSIS.  181 

descriptions  above  given.  One  of  these  was  in  a  young 
man,  in  whom  the  spitting  had  been  somewhat  profuse 
and  had  recurred  several  times.  He  was  treated  under 
the  direction  of  a  very  distinguished  physician  of  the 
day,  —  fifty  years  ago,  —  who  prescribed  Huxham's 
tincture  of  bark,  and  stimulants  generally.  The  phy- 
sician took  it  for  granted,  as  did  most  medical  men  at 
the  time,  that  the  bleeding  was  due  to  the  rupture  of 
an  artery  ;  and  he  explained  his  practice  in  this  way. 
He  said  that  two  pieces  of  iron  could  not  be  welded 
together  unless  they  were  red-hot ;  and  that  two  raw 
surfaces  must  be  strongly  excited  to  make  them  heal 
together.  Twenty  years  afterwards  I  saw  another 
patient  who  died  under  haemoptysis.  She  was  a  ten- 
der and  delicate  "woman ;  not  pampered ;  the  wife  of  a 
mechanic.  .  During  a  year  or  more  she  had  attacks  of 
haemoptysis  several  times.  In  the  last  attack  I  was 
summoned  to  her  hastily,  and  on  entering  the  room 
found  her  sitting  up  in  bed,  with  a  bowl  before  her. 
into  which  she  was  spitting  blood.  Her  whole  aspect 
showed  that  she  was  much  exhausted.  I  passed  round 
her  bed  so  as  to  stand  between  her  and  the  window, 
where  I  could  see  and  examine  her  best.  When  1 
reached  this  point,  in  a  moment  she  fell  back  and 
expired.  She  died  from  the  loss  of  blood,  not  from 
16 


182  ON   PHTHISIS   AND   HiEMOPTYSIS. 

suffocation.  In  the  preceding  case  I  could  not  get 
leave  to  make  an  examination  of  the  bodj;  but  in  this 
last  case  I  was  more  fortunate.  I  was  assisted  in  the 
examination  by  the  late  Dr.  John  G.  Gorham.  Before 
opening  the  body,  I  stated  that  there  were  two  ques- 
tions to  be  kept  in  mind.  One  was,  whether  there  were 
tubercles.  The  patient  had  never  had  cough  to  any 
amount,  nor  had  she  had  hectic  fever.  The  other 
question  was,  how  we  should  ascertain  whether  there 
had  been  rupture  of  a  blood-vessel.  On  this  point  I 
said,  if  a  vessel  has  been  ruptured,  we  shall  find  an 
ecchymosis  containing  a  sufficient  quantity  of  coagu- 
lated blood  to  form  a  little  knot,  or  hard  mass.  I 
grounded  this  remark,  first  upon  experience,  having 
once  opened  a  body  where  hemorrhage  had  taken  place 
into  the  cavity  of  the  peritoneum,  such  as  to  cause 
death  in  a  few  hours.  In  this  case,  having  removed 
the  blood,  after  a  careful  search,  I  discovered  that  in 
one  of  the  ovaries  there  was  an  appearance  of  an 
ecchymosis ;  and,  at  this  point,  there  was  a  rupture 
of  the  ovary,  and  around  it  an  induration.  I  believe 
that  the  nature  of  this  accident  in  the  ovary  is  now 
well  understood,  and  I  will  not  stop  to  remark  upon 
it.  But  the  appearance,  which  I  had  observed,  led  me 
to  this  view  of  the  subject.  Whenever  a  blood-vessel 
is  ruptured,  so  that  the  blood  shall  escape  from  it,  a 


ON   PHTHISIS   AND   HEMOPTYSIS.  18o 

portion  of  this  blood  must  be  retained  and  coagulate 
in  the  cellular  membrane  around  the  rupture.  If  you 
reflect  on  the  matter,  you  will  see  that  this  must  hap- 
pen, wherever  the  blood-vessel  is  situated;  whether 
immediately  under  a  serous  membrane,  so  that  that 
membrane  is  also  ruptured,  and  thus  the  blood  is 
poured  into  the  serous  cavity ;  or  whether  in  the  im- 
mediate vicinity  of  a  bronchus,  where  the  rent  is  con- 
tinued into  the  bronchus,  so  that  the  blood  may  issue 
through  the  mouth.  Or,  again,  if  the  vessel  is  situ- 
ated in  the  middle  of  any  organ,  surrounded  by  a 
large  mass  of  solid  matter,  the  same  ecchymosis  must 
be  formed  ;  for,  in  every  case,  the  vessel  is  immediately 
connected  with  the  surrounding  parts  by  the  cellular 
membrane.  Therefore,  in  the  case  before  us,  I  deter- 
mined to  feel  carefully  in  every  part  of  the  lung,  and 
wherever  I  should  discover  an  indurated  portion, 
however  small,  to  cut  into  that. 

Proceeding  with  these  views,  I  opened  the  body. 
On  inspection  nothing  was  to  be  seen  of  an  abnormal 
kind  on  the  face  of  the  lungs.  Then  I  divided  the 
trachea,  when  I  found  its  branch  on  the  right  side 
stained  with  blood,  while  that  on  the  left  was  not  so. 
I  divided  this  right  bronchus,  and  pursued  the  dissec- 
tion, taking  the  stain  of  blood  for  my  guide,  and  in 
this  way  was  led  to  open  some  three  or  four  branches 


184  ON   PHTHISIS   AND   HiEMOPTYSIS. 

of  some  size,  with  their  subdivisions.  While  doing 
this  I  watched  carefully  for  any  appearance  of  an 
ecchymosiSj  but  did  not  find  any.  Thus  far,  I  had 
handled  the  lung  as  little  as  was  consistent  with  the 
examination  made.  Now  I  felt  over  every  part  of  it, 
going  over  it  slowly  and  carefully ;  and  wherever  I 
could  feel  between  my  thumb  and  finger  the  small- 
est knob,  I  laid  the  part  open.  But  the  parts,  to 
which  I  was  thus  led,  were  none  of  them  abnormal ; 
nor  could  I  anywhere  discover  the  appearance  of  an 
ecchymosis.  It  is  equally  true  that  I  could  not  dis- 
cover any  tubercles.  In  short,  except  the  blood  in  the 
bronchi,  nothing  abnormal  was  discovered.  The  left 
lung  was  examined  more  cursorily,  but  there  was  no 
stain  of  blood  in  its  principal  bronchus. 

I  may  seem  to  have  been  more"  minute  than  neces- 
sary in  describing  the  examination  in  this  case.  My 
reason  for  being  so  is,  that  I  assert  a  negative,  namely, 
that  there  was  not  any  appearance  of  a  ruptured  blood- 
vessel in  the  lung.  It  was,  therefore,  necessary  to 
show  that  I  guarded  against  all  chances  of  error. 
Besides,  though  the  opinion  I  maintain,  that  in  com- 
mon cases  of  haemoptysis  the  blood  is  discharged 
through  the  exhalants  and  not  through  a  wound  in  an 
artery  or  vein,  is  now  generally  received,  I  do  not 
recollect  ever  to  have  seen  such  evidence  advanced  in 


ON   PHTHISIS   AND   HAEMOPTYSIS.  185 

its  support,  as  this  case  affords.  I  am,  therefore, 
desirous  to  show  that  the  statement  may  be  relied  on. 
If  we  take  this  case  alone,  supposing  that  I  was  not 
guilty  of  any  oversight,  it  wo  aid  seem  certain  that  the 
blood  escaped  from  its  vessels  through  the  extreme 
arteries,  the  exhalants.  As  there  were  no  tubercles 
in  this  case,  I  may  not  be  justified  in  saying  that 
haemoptysis  in  tuberculous  subjects,  occurring  in  the 
early  stages  of  the  disease,  takes  place  in  the  same 
manner ;  but  this  case  shows  that  bleeding,  sufficient 
to  destroy  life,  may  take  place  by  exudation.  I  feel 
no  doubt  that  it  does  happen  in  this  way  in  the 
tuberculous  cases.  Although  such  an  opinion  was  not 
very  commonly  received  in  my  earlier  days,  I  believe 
that,  at  this  day,  there  are  few  pathologists  who  enter- 
tain any  doubt  on  the  subject. 

It  should  be  noted  that,  when  blood  is  spit  from  the 
mouth,  it  does  not  necessarily  come  from  the  lungs ; 
and  the  interesting  question,  always  urged  by  the 
patient  or  his  friends,  is,  whether  it  has  been  derived 
from  those  organs.  The  blood  discharged  from  the 
mouth  may  be  poured  out  from  the  exhalants,  or  larger 
vessels,  directly  into  that  part.  I  once  saw  a  lady 
frequently  spitting  blood,  in  small  quantities,  which 
oozed  out  from  one  of  her  gums.  When  the  blood  was 
wiped  off,  the  gum  showed  itself  beautifully  firm  and 
16* 


186  ON  PHTHISIS  AND   HEMOPTYSIS. 

not  at  all  red.  All  her  teeth  and  gums  were  perfectljP 
sound.  Ordinarily,  the  blood  is  derived  from  the  back 
part  of  the  nose,  or  from  the  fauces,  from  the  gullet 
or  stomach,  or  from  the  lungs.  It  is  not  difficult, 
generally,  even  to  common  observers,  to  discover  by 
the  manner  whether  the  blood  is  derived  from  the 
patient's  mouth.  If  the  amount  is  at  all  large,  by 
compressing  the  mouth  and  the  parts  around  it,  the 
patient  will  promote  the  flow,  and  spit  the  blood  with- 
out any  such  effort  as  would  be  requisite  to  bring  it 
forward,  even  from  the  fauces.  If  the  bleeding  is  in 
the  fauces,  it  may  be  discovered  on  inspection,  in 
some  instances ;  and,  if  in  any  quantity,  it  will  be 
brought  forward,  just  as  is  frequently  done  with 
mucus.  If  from  the  nose,  some  of  the  blood  will 
probably  pass  through  the  nostrils ;  but,  if  not,  the 
patient  may  draw  it  down  and  bring  it  into  the  mouth, 
just  as  he  does  with  regard  to  mucus  when  lodged  in 
the  posterior  nares.  If  the  bleeding  is  in  the  gullet  or 
stomach,  it  will  be  brought  up  by  vomiting  ;  if  from 
the  lungs,  by  coughing  or  hawking.  It  must  be  plain 
that  blood  will  not  run  up  from  the  stomach,  or  lungs, 
against  gravity.  I  say  this,  because  when  it  is  from 
the  lungs,  the  patient  often  believes  that  it  flows 
up  without  either  coughing  or  hawking.  I  pre- 
sume it  must  always  be  brought  up  by  one  of  those 


ON   PHTHISIS   AND   HEMOPTYSIS.  187 

eiFortSj  though  the  patient  and  even  the  bystanders 
sometimes  think  otherwise.  If  it  ever  does  happen 
otherwise,  I  think  it  must  be  where  an  aneurism  has 
been  ruptured,  and  the  blood  is  driven  forward  by  the 
power  of  the  heart.  In  this  case,  if  the  patient  be 
lying  in  a  position  nearly  horizontal,  I  presume  that 
the  blood  may  flow  through  the  windpipe  into  the 
fauces  and  mouth.  Generally,  then,  if  a  patient  be 
spitting  blood  from  the  lungs,  he  raises  it  by  coughing 
or  hawking.  If  this  be  not  apparent  at  first,  when 
the  blood  is  flowing  copiously,  it  becomes  so,  when  the 
bleeding  slackens,  and  the  coughing  or  hawking  takes 
place  deliberately.  In  all  this,  I  have  reference  to  a 
patient  previously  well,  or,  at  least,  not  much  advanced 
in  phthisis.  We  must  distinguish,  in  such  cases,  the 
discharge  of  a  few  drops  of  blood,  whether  pure,  or 
mixed  with  mucus,  from  such  a  flow  as  that  the 
patient  spits  out  a  mouthful  at  a  time.  When  it 
comes  in  the  smaller  quantity,  it  may  be,  if  not  from 
the  fauces,  from  the  larynx,  or  trachea.  Some  persons 
will  very  frequently  spit  some  drops  of  blood  in  this 
way,  evidently  derived  from  the  trachea,  there  being 
at  the  time  other  symptoms  showing  disease  in  that 
part,  while  there  are  no  physical  signs  of  disease  in 
the  lungs.  As  such  cases  excite  unnecessary  alarm,  I 
wish  to  make  some  remarks  on  them.     We  are  told 


188  ON   PHTHISIS  AND   HAEMOPTYSIS. 

that  they  are  attended  with  danger,  for  that  the 
disease  may  travel  down  from  the  trachea.  I  will  not 
say  that  this  is  not  true,  for  that  would  be  asserting 
a  universal  negative  —  a  very  hard  thing  to  prove  ;  but 
I  will  say  that  I  have  watched  this  matter  for  a  long 
while,  and  have  not  seen  any  instance,  in  which 
tuberculous  disease  travelled  in  this  course.  I  have 
often  seen  patients  have  this  trouble  in  the  windpipe, 
and  afterwards  die  of  phthisis  ;  but  these  persons  have 
had  the  signs  of  disease  in  the  lungs  as  early,  or 
earlier,  than  the  signs  of  disease  in  the  windpipe. 

When  pulmonary  haemoptysis  does  take,  place,  it 
varies  much  in  the  circumstances  attending  it,  and  in 
the  quantity  of  blood  which  is  raised.  It  is  most 
commonly  preceded  by  cough,  or  by  some  pain,  or 
other  uncomfortable  feeling,  in  the  chest.  This  feeling 
may  be  a  sense  of  fulness,  or  a  stricture  in  the  chest, 
so  that  some  difficulty  of  breathing  is  felt,  though  not 
manifested  to  bystanders.  These  local  symptoms  may 
occur  with  the  haemoptysis,  if  they  do  not  precede  it. 
Febrile  symptoms  attend  the  spitting,  in  some  in- 
stances, especially  an  acceleration  of  the  pulse.  But 
in  other  cases  the  hemorrhage  comes  on-  quite  alone. 
It  is  not  rare  for  the  patient  to  tell  you  that  he  had 
had  some  cough,  or  some  uneasiness  in  the  breast,  but 
that  he  awoke  in  the  morning  feeling  uncommonly 


0^    PHTHISIS   AND   HEMOPTYSIS.  189 

well,  and  soon  after  the  blood  began  to  come  up.  As 
I  write,  I  recall  three  instances  among  mj  friends, 
each  of  whom  had  been  riding  the  day  before,  and  who 
awoke  in  a  morning  with  this  comfortable  feeling,  and  in 
each  case  within  an  hour  a  free  hemorrhage  took  place. 
But  if  there  have  not  been  any  morbid  feelings  or 
other  signs  of  disease  before,  nor  at  the  beginning  of 
the  haemoptysis,  this  is  often  followed  by  cough  and 
constitutional  symptoms.  Yet  cases  do  occur  in  which 
there  are  scarcely  any  symptoms  of  disease,  other  than 
the  bleeding,  before,  or  for  a  long  time  after,  its  occur- 
rence, though  at  a  later  period  phthisis  becomes  manifest. 
In  most  cases  the  haemoptysis  returns  once,  or  several 
times,  before  any  other  strong  manifestation  of  disease 
takes  place.  In  such  instances  the  termination  of  the 
whole  may  be  from  two  to  ten  years  after  the  first 
bleeding. 

In  the  great  majority  of  cases  the  hemorrhage 
subsides  spontaneously  without  any  medicine  ;  but  in 
some  it  is  too  copious  to  be  trusted.  From  what  has 
been  before  said,  we  may  ordinarily  assure  the  patient 
that  there  is  not  any  present  danger.  This  is  often 
important  to  calm  the  agitation  of  mind.  With  the 
same  view,  it  is  proper  to  administer  some  medicine 
known  to  have  a  good  tendency,  but  not  of  a  kind  to 
produce  any  inconvenience.    A  popular  remedy,  often 


190  ON   PHTHISIS  AND   HEMOPTYSIS. 

employed  by  physicians,  is  common  salt.  This  is 
taken  in  a  dry  state,  or  more  comfortably  in  a  strong 
solution.  A  more  agreeable  remedy  is  the  diluted 
sulphuric  acid.  Of  this  twenty  drops  may  be  taken 
m  sweetened  water,  and  the  same  repeated  once  in 
three  or  four  hours,  till  the  bleeding  ceases.  Rest 
of  body  and  mind,  and  ''  holding  the  tongue,"  are 
quite  as  important,  at  the  moment  of  the  bleeding,  as 
the  medicinal  articles.  When  the  blood  comes  up 
very  copiously  for  some  time,  I  employ  more  potent 
remedies,  particularly  the  sulphate  of  copper  with 
opium.  The  opium  is  useful  in  diminishing  the  cough, 
by  which  the  bleeding  is  promoted.  The  sulphate 
acts  as  an  astringent,  as  I  suppose.  More  of  this  can  be 
used  in  a  pill  than  in  a  liquid  state.  From  a  quarter 
of  a  grain  to  a  grain  may  be  given  at  once,  and  this 
may  be  repeated  in  six,  or  twelve  hours,  if  the  hemor- 
rhage does  not  cease,  unless  too  much  nausea  is 
produced.  If,  however,  it  occasions  vomiting,  the 
bleeding  is  not  increased,  but  rather  checked  by  it. 
In  an  urgent  case,  which  had  continued  four  days,  and 
which  I  then  saw  in  consultation,  I  gave  a  grain  of 
the  sulphate  with  an  equal  quantity  of  opium.  The 
bleeding  lessened  very  much  soon  after ;  a  second 
dose  was  given  at  the  end  of  twelve  hours,  from  which 
time    the  bleeding  ceased.     No  inconvenience   was 


ON   PHTHISIS  AND   HEMOPTYSIS.  191 

experienced  from  the  copper.  A  single  case  like  this 
is  not  oflfered  as  a  proof ;  but  this  came  to  me  in  corrob- 
oration of  the  benefit  in  many  other  cases,  where  there 
was  hemorrhage  from  other  parts  of  the  body,  besides 
the  lungs.  I  have  formerly  made  great  use  of  blisters 
and  the  like  remedies  in  cases  of  haemoptysis,  but  I 
gradually  discontinued  them  from  a  conviction  that 
they  were  not  necessary,  and  that  they  were  sometimes 
injurious.  Yet  I  incline  to  the  belief  that,  when  the 
bleeding  continues  for  several  days,  the  tendency  may 
be  checked  by  a  very  small  blister,  or  by  the  use  of 
croton  oil,  over  a  surface  not  more  than  an  inch  in 
diameter ;  and  by  the  repetition  of  this,  when  the 
bleeding  does  not  cease. 

Bloodletting  has  been  often  employed  in  this  affec- 
tion, with  a  view  to  guard  against  subsequent  disease 
of  the  lungs,  as  well  as  to  arrest  the  bleeding.  I 
have  very  rarely  seen  an  instance,  where  it  seemed  to 
me  to  be  called  for  ;  yet  it  may  sometimes  be  useful. 
I  think  it  was  so  in  the  case  of  one  of  my  younger 
medical  friends  in  a  neighboring  town.  His  case 
presents  some  points  of  interest,  so  that  I  think  it 
worth  stating  to  you.  It  occurred  more  than  twenty 
years  ago,  and  I  am  happy  to  say  that  the  patient  is 
now  alive  and  in  good  health. 

In  August,  1831,  I  was  called  to  see  my  friend, 


192  ON   PHTHISIS   AND   HiEMOPTYSIS. 

Dr.  Hosmer,  of  Watertown.  and  found  him  raising 
blood  from  the  lungs  in  a  very  unusual  quantity.  He 
hadj  as  I  knew,  been  frequently  spitting  blood  for  a 
year  preceding,  in  very  small  quantities,  but  had  main- 
tained good  health,  and  was  engaged  in  a  very  exten- 
sive business  in  a  circle  of  five  miles'  radius.  I  now 
found  him  very  hot,  with  a  frequent  and  hard  pulse. 
The  case  was  so  urgent  that  both  he  and  I  thought  it 
most  prudent  that  he  should  be  bled.  I  bled  him 
twice  within  twenty-four  hours,  a  pint  each  time  ;  and 
we  calculated  that  he  could  not  have  raised  less  than 
two'pints  of  blood.  We  came  to  this  conclusion  with 
the  utmost  caution,  fully  aware  of  the  common  exag- 
geration on  this  point.  We  thought  that  he  was  ben- 
efited by  the  venesection.  He  was,  of  course,  much 
weakened,  and  for  some  hours  quite  insensible;  but 
the  haemoptysis  ceased,  and  he  soon  began  to  recover 
his  strength.  At  the  end  of  six  weeks  he  was  so  well 
that  he  could  not  easily  keep  out  of  business  if  he  re- 
mained at  home ;  he  therefore  went  to  the  place  of  his 
nativity,  where  he  could  take  exercise  freely  in  the  open 
air  without  being  obliged  to  attend  to  patients.  There 
he  spent  three  or  four  months.  The  winter  was  very 
cold,  and  he  was  abroad  every  day.  He  then  returned 
well  enough  to  resume  his  practice.  The  plan  I  laid 
down  for  him  was  to  live  on  milk  and  vegetable  food, 


ON   PHTHISIS   AND   HEMOPTYSIS.  193 

and  to  keep  abroad  in  all  weathers,  as  much  as  pos- 
sible on  horseback,  but  to  avoid  exposure  in  the  night. 
In  the  ensuing  spring  and  summer  he  gained  flesh  and 
strength ;  but,  in  September  following,  he  told  me 
that  he  continued  to  spit  a  little  blood  occasionally, 
and  that  his  pulse  would  be  accelerated  at  the  time,  so 
that  he  had  taken  a  little  blood  from  his  arm,  on  an 
average,  once  a  month.  On  an  investigation  of  the 
case,  I  learned  that  he  had  found  it  so  inconvenient  to 
ride  on  horseback,  that  he  travelled  mostly  on  wheels 
in  attending  to  his  business.  I  urged  him  to  submit 
to  the  inconvenience,  and  to  stick  to  his  horse.  He  did 
so,  and  his  first  ride  was  too  far  and  too  hard.  This 
was  followed  by  a  new  haemoptysis.  After  that  he 
began  by  riding  moderately,  but  did  stick  to  his  horse, 
and  he  ceased  to  spit  blood  from  that  time.  He  has 
now  for  many  years  been  in  full  flesh,  with  a  fine 
color,  and  appears  very  strong.  He  has  been  con- 
stantly engaged  in  active  business.  After  one  year 
he  returned  to  common  diet,  and  after  a  year  more  he 
gave  up  the  riding  on  horseback. 

During  the  hemorrhage  I  could  not  make  a  good 
exploration  of  the  chest  without  incommoding  him  too 
much.  After  his  recovery  I  examined  him  carefully, 
more  than  once,  without  discovering  any  physical  sign/? 
of  disease  in  the  lungs. 
IT 


194  ON   PHTHISIS   AND   HiEMOPTYSIS. 

Dr.  Hosmer's  case  was  an  uncommon  one.  I  have 
seen  instances  where  the  bleeding  has  been  very 
copious,  but  none  where  it  has  been  so  large  as  in 
his  ;  nor  have  other  circumstances  been  similar.  But 
I  have  seen  others,  for  whom  I  have  ordered  the  same 
diet  as  I  did  for  him,  and  I  have  believed  that  advan- 
tage was  derived  from  it.  They  have  been  instances 
in  which  the  constitution  has  shown  vigor,  and  in 
which  the  patient  has  kept  up  strength  and  flesh  upon 
the  diet.  In  cases  where  the  cachexy,  so  common  to 
tuberculous  subjects,  has  shown  itself,  I  have  never 
ventured  to  forbid  the  use  of  animal  food.  On  the 
contrary,  I  have  advised  this  food,  as  far  as  the  appe- 
tite would  permit,  at  least  once  a  day. 

You  will  observe,  in  Dr.  Hosmer's  case,  that  as  soon 
as  the  copious  hasmoptysis  had  ceased,  and  the  patient 
had  regained  sufficient  strength,  I  advised  him  to  take 
active  exercise  in  the  open  air.  A  fear  is  sometimes 
entertained  that  the  bleeding  may  be  brought  on  in 
this  way.  By  long-continued  and  exhausting  fatigue, 
this  may  be  ;  and  the  same  after  an  unusual  and  vio- 
lent exertion,  as  above  stated  in  his  case  ;  but  such  a 
patient  may  be  brought  to  very  free,  active  exercise, 
regardless  of  weather,  without  any  injury,  but  with 

benefit.     Captain  L belonged  to  a  consumptive 

family,  and  he  was,  I  may  say,  in  the  habit  of  spitting 


ON   PHTHISIS  AND   HEMOPTYSIS.  195 

blood  frequently  for  several  years.  He  had  some 
other  unpleasant  symptoms.  He  was  very  fond  of 
sport,  and,  after  some  experience  in  the  case,  he 
adopted  the  practice  of  taking  his  gun  and  dog,  and 
following  the  birds  for  several  days,  when  the  bleed- 
ing took  place,  if  the  season  permitted  it.  He  found 
that  he  got  through  the  trouble  in  this  way  better 
than  in  any  other.  His  bleedings  were  not  very 
copious,  though  not  trivial,  and  were  not  attended  by 
fever.  He  lived  many  years  after  the  period  when  I 
knew  him,  enjoying  tolerably  good  health,  and  died 
suddenly  of  an  acute  disease.  In  this  case  the  prac- 
tice was  not  prescribed  by  myself,  though  I  encouraged 
a  continuance  in  it. 

I  am  induced  to  go  somewhat  largely  into  this  sub- 
ject, because,  while  haemoptysis  is  justly  regarded  as  a 
precursor  of  phthisis,  there  is  a  chance  for  avoiding 
this  termination  for  a  time,  and  even  for  a  long  life. 
And,  where  the  health  does  not  break  down  imme- 
diately after  the  bleeding,  there  is  a  period  when  much 
is  to  be  done  for  the  security  of  the  patient.  I  say, 
then,  that  a  patient,  spitting  blood,  may  be  assured 
that  there  is  a  good  chance  for  his  having  some  years 
of  good  health,  and  some  chance  for  a  long  life,  even 
though  he  be  young  when  the  bleeding  occurs.     I 


196  ON   PHTHISIS   AND   HEMOPTYSIS. 

could  bring  many  instances  to  support  this  statement. 
I  will  mention  some  of  them. 

In  this  city  there  are  three  gentlemen,  whose  busi- 
ness brings  them  daily  within  a  few  doors  of  each 
other,  now  in  good  health,  but  who  have  raised  blood 
freely  from  the  lungs.  One  of  them  belongs  to  a  con- 
sumptive family.  His  mother  died  of  phthisis,  and 
one  brother  and  three  sisters  of  his,  all  adults,  died 
within  a  few  years  after  he  first  raised  blood.     He, 

Mr.  L ,  was  about  twenty  years  of  age  when  he 

was  taken  with  a  copious  haemoptysis.  He  was  on 
a  voyage  to  Calcutta.  This  was  in  the  year  1802. 
For  some  years  after  this  he  was  much  troubled  with 
cough,  often  accompanied  by  pain  in  the  chest,  and  at 
times  with  sputa  to  a  large  amount.  In  these  sputa 
there  was,  not  rarely,  a  little  blood.  After  the  first 
years  he  occasionally  expectorated  cretaceous  matter, 
in  tlie  whole  to  a  large  amount.  This  was  evidence 
that  he  had  tubercles.  He  has  been  free  from  such 
troubles  for  many  years,  though  he  has  frequently 
had  bronchitis,  and  sometimes  this  has  been  protract- 
ed. He  now  enjoys  a  green  old  age.  His  habits 
have  always  been  active ;  and  while  his  lungs  were 
much  threatened  he  travelled  a  good  deal.  He  has 
had  six  children  and  many  grandchildren.  Of  his 
children  one  only  has  had  phthisiSj  and  the  youngest 


ON   PHTHISIS  AND   HEMOPTYSIS.  197 

is  now  nearly  thirty  years  of  age.  This  case  alone 
should  give  encouragement  to  persons  affected  with 
this  disease. 

Of  the  other  two,  one  spit  blood  largely  for  several 
days,  and  was  necessarily  confined  to  his  bed,  in  1818. 
He  is  noAV  alive  and  well.  The  other  spit  blood  freely 
in  April,  1838,  and  this  was  very  often  repeated  for 
six  months.  He  was  much  reduced  in  flesh  and 
strength,  though  he  kept  on  his  feet.  In  October,  he 
was  very  short-breathed,  and  had  a  cough.  He  went 
abroad  at  this  time,  and  returned  the  next  summer  in 
much  better  condition.  Gradually  he  recovered  his 
health,  and  has  been  constantly  engaged  in  an  active 
life  to  this  day.  I  should  say  that,  on  his  return  from 
his  travels,  I  examined  him  carefully,  and  could  not 
find  any  physical  sign  of  disease  in  his  chest.  Others, 
most  worthy  of  reliance,  had  thought  at  early  periods 
that  they  had  discovered  some  slight,  yet  unequivocal 
signs  of  tubercles.  I  trust,  from  feelings  very  differ- 
ent from  personal  vanity,  that  my  conclusion  will  be 
justified  by  a  long  life. 

I  could  give  other  examples  of  the  same  kind.  But 
I  wish  now  to  state  two  cases,  where  life  was  con- 
tinued for  more  than  twenty  years  after  haemoptysis, 
and  where  the  disease  was  proved  to  be  tuberculous. 
One  of  these  was  a  valued  friend  of  mine,  my  clags- 
17^ 


198  ON   PHTHISIS  AND   HEMOPTYSIS. 

mate  in  college,  and  a  physician  in  this  citj.  He 
consulted  me  after  having  spit  blood  copiously  two  or 
three  times.  The  particular  object  of  the  consulta- 
tion was  to  decide  whether  it  was  expedient  for  him  to 
take  up  his  residence  in  a  southern  climate.  This 
would  have  been  very  inconvenient  to  him,  as  he  must 
have  left  a  lucrative  business  here.  He  had  a  very 
good  frame,  and  had  always  before  enjoyed  good 
health.  I  advised  him  not  to  make  the  change.  I 
stated  the  opinion,  which  I  had  then  entertained  for 
some  years,  and  which  has  been  confirmed  by  all  my 
subsequent  experience,  namely,  that  the  most  impor- 
tant thing  for  all,  threatened  with  phthisis,  is  to 
lead  an  active  life  in  the  open  air ;  and  that,  if  they 
cannot  do  that  without  too  much  suffering  in  our  cold 
climate,  they  should  go  to  a  warmer  one,  where  they 
can  do  it ;  but  that  this  step  is  seldom  necessary,  ex- 
cept for  those,  who  have  been  in  the  habit  of  keeping 
much  in-doors.  As  he  had  passed  his  life  in  profes- 
sional business,  he  had  not  become  tender.  He  was, 
however,  accustomed  to  drive  about  in  a  gig,  and  I 
advised  that  he  should  ride  as  much  as  possible  on 
horseback.  I  advised  also  milk  and  vegetable  food  for 
his  diet,  for  a  year  or  two.  He  pursued  this  course, 
and  he  lived  about  twenty-two  years  after  the  haemop- 
tysis occurred.     During  this  period  he  had  a  cough 


ON   PHTHISIS  AND   HiEMOPTYSIS.  199 

occasionally,  and,  perhaps,  a  little  at  all  times;  but 
he  pursued  his  business,  and  was  often  out  in  the  night. 
A  few  years  before  his  death  he  was  confined  several 
weeks,  and  was  somewhat  reduced  by  an  attack  on  his 
lungs,  the  precise  character  of  which  I  do  not  now 
remember.  But,  in  general,  he  kept  in  good  flesh  and 
strength,  and,  having  a  florid  countenance,  he  had  the 
appearance  of  perfect  health.  His  death  took  place 
from  an  acute  pneumonitis,  on  the  right  side,  of  only 
five  days'  continuance.  I  saw  him  the  day  before  his 
death,  when  respiration  was  very  difiicult ;  but  till 
that  day  he  did  not  believe  his  disease  to  be  very  seri- 
ous. On  examination,  the  lower  two-thirds  of  the 
right  lung  were  found  in  a  state  of  acute  inflammation. 
At  the  apex  of  each  lung  was  found  a  cavity,  that  of 
the  right  being  the  largest.  Each  contained  a  small 
mass  of  putty-like  matter,  of  a  brown  color.  Every 
appearance  showed  that  these  cavities  were  very  old. 

The  other  case  was  that  of  a  clergyman,  who  was 
about  twenty-five  years  old  when  first  attacked  by 
haemoptysis.  He  was  a  more  feeble  man  than  the 
other,  but  he  lived  about  twenty  years  after  his  attack. 
During  sixteen  or  more  of  these  years  he  performed 
the  duties  of  his  oflBce,  and  had  tolerably  good  health, 
though  he  was  never  very  strong.  For  several  months 
before  his  decease  he  was  obliged  to  give  up  the  duties 


200  ON  PHTHISIS   AND   HEMOPTYSIS. 

of  the  church,  and  at  last  died  suddenly  under  a  pro- 
fuse hsemoptysiSj  such  as  I  have  described  as  some- 
times occurring  in  the  last  stage  of  phthisis.  There 
was  not  any  examination  of  his  body,  but  the  physical 
and  rational  signs  had  given  unequivocal  evidence  of 
tuberculous  cavities  long  before  death.  He  had  always 
kept  up  the  habit  of  exercise  abroad,  and  at  times, 
especially  in  the  first  years,  had  taken  much  active 
exercise.  He  had  not  done  this  so  much  as  I  wished, 
yet,  undoubtedly,  he  was  supported  very  much  by 
what  he  did  do. 

I  have  selected  these  cases  from  others,  because  the 
patients  were  my  friends,  and  I  kept  their  histories  in 
remembrance.  Such  cases  may  be  held  up  to  patients 
as  an  encouragement  to  make  exertions.  You  will  not 
suppose  that  I  should  expect  every  one  to  prolong  life 
as  much  as  these  persons  did,  under  the  like  difficulties. 
But  where  the  constitution  shows  good  vigor,  if  the 
patient  can  take  and  bear  food,  and  if  not  deficient  in 
muscular  power,  you  may  hold  up  to  him  bright  hopes, 
provided  he  will  steadfastly  pursue  the  right  course. 
I  had  another  clergyman  under  my  care,  who  adhered 
carefully  to  my  rules  after  his  first  haemoptysis,  which 
was  in  1812,  for  four  years,  and  appeared  quite  rees- 
tablished in  his  health,  though  he  had  been  a  good 
deal  reduced  before  I  saw  him.     Late  in  1816  he  seut 


ON   PHTHISIS   AND   HEMOPTYSIS.  201 

for  me  on  account  of  a  second  haemoptysis.  Being 
very  conscientious,  he  stated  to  me,  as  soon  as  I  came 
near  him,  that  for  four  months  preceding  he  had  not 
adhered  to  my  rules.  These  were  not  rules  as  to 
medicine,  for  I  had  not  given  him  any ;  but  rules  as 
to  exercise  in  the  open  air.  From  this  time  he  grew 
more  sick,  and  died  about  eighteen  months  afterwards. 
It  is  an  opinion  often  advanced  that  clergymen  are 
more  liable  than  others  to  haemoptysis,  and  to  other 
diseases  of  the  lungs.  It  is  thought  that  they  suffer 
from  public  speaking.  I  feel  assured  that  this  is  not 
true.  Besides  what  I  have  mentioned,  I  could  refer 
to  one  in  a  neighboring  city  who  raised  blood  copiously 
thirty  years  ago,  soon  after  he  began  to  preach.  He 
was  troubled  for  some  time  with  weakness  of  voice, 
and  difficulty  of  breathing,  attended  by  a  very  quick 
pulse.  He  followed  my  advice  with  a  good  and  deter- 
mined spirit.  He  has  been  a  preacher  the  whole  time, 
with  the  exception  of  one  or  two  years  in  the  begin- 
ning, and  has  had  very  good  health.  I  have  not  the 
least  doubt  that  he  has  tubercles  in  his  lungs.  It  is 
supposed  that  clergymen  must  suffer  from  the  amount 
of  their  public  speaking.  The  truth  is  that  there  are 
men  in  other  professions  who  try  their  voices  much 
more  than  clergymen  do.  Such  are  professors  in 
medical  schools,  many  of  whom  lecture  six  days  in  the 


202  ON   PHTHISIS   AND   HEMOPTYSIS. 

week  for  three  or  four  months.  It  is  true  that  they 
speak  in  rooms  comparatively  small,  but  it  is  usually 
for  an  hour  without  resting.  Lawyers  and  members 
of  legislative  bodies  often  speak  from  two  to  four  hours 
at  a  time.  In  respect  to  the  strenuous  exertion  of  the 
voice,  there  are  many  auctioneers  who  go  far  before 
-clergymen.  Now,  I  have  been  in  the  way  of  many 
persons  of  these  descriptions,  and  have  not  found  them 
subject  to  spitting  of  blood. 

I  am  tempted  to  relate  more  cases  of  haemoptysis, 
in  which  the  results  have  been  favorable,  for  they  rise 
in  my  mind  as  I  write ;  but  I  should  cover  too  many 
pages.  I  do  not  pretend  to  offer  you  such  a  statement, 
in  respect  to  numbers,  as  I  might  have  done  if  I  had 
kept  notes ;  and,  therefore,  you  will  consider  what  I 
do  give  you,  as  illustrating  the  effect  of  the  principles 
I  advance,  not  as  proving  them  to  be  true. 


LETTER  XII. 

ON   DYSPEPST. 

I  WILL  now  call  your  attention  to  diseases  in  the 
abdominal  organs ;  and,  first,  to  dyspepsy.  The 
proper  office  of  the  stomach  is  to  digest  the  food.  The 
digestion  consists  in  dissolving  or  softening  the  food  so 
as  to  bring  it  into  a  pultaceous  mass,  and  in  bringing 
about  in  this  mass  certain  changes  as  to  the  chemical 
composition  of  some  of  its  proximate  elements.  In 
health,  this  function  is  performed  with  ease,  not  calling 
attention  to  the  organ  in  which  it  is  taking  place,  but 
rather  inducing  a  comfortable  and  grateful  feeling 
over  the  whole  system,  body  and  mind.  But  some- 
times there  is  a  difficulty  in  the  process,  causing  unea- 
siness in  the  stomach,  and  more  or  less  elsewhere.  To 
this  difficulty  we  give  the  name  of  dyspepsy.  We  do 
not,  however,  apply  this  name  to  a  temporary  or 
casual  indigestion,  but  to  a  labor  in  the  function  which 
recurs  daily,  or  very  frequently.  It  is  not  implied  in 
this  description  that  the  digestion  does  not  take  place. 


204  ON   DTSPEPSY. 

It  maj  be  effected  perfectly,  but  it  is  done  with  diffi- 
culty ;  this  is  all  that  is  essential  to  the  disease.  It 
is  nevertheless  true  that  there  is,  probably,  in  the 
great  majority  of  instances,  some  imperfection  in  the 
results  of  the  action  of  the  stomach.  There  is,  of 
course,  every  variety  in  the  degree  of  difficulty,  or 
amount  of  extra  labor,  in  the  cases  of  dyspepsy.  Hence 
must  arise  some  difference  in  the  manifestations  of  the 
disease. 

But  there  are  symptoms  accompanying  dyspepsy, 
arising  from  other  sources,  -which  we  must  keep  in 
view  if  we  would  understand  the  disease.  They  are 
those  which  are  derived,  not  from  the  stomach,  but  from 
the  other  organs  of  the  abdomen  connected  with  it. 
Those  other  organs  are  the  intestines,  large  and  small, 
the  liver,  pancreas  and  spleen.  These  three  last  I 
call  the  subsidiary  organs,  and  of  these  the  liver 
is  most  noted.  This  is  the  largest  of  the  three 
organs;  its  functions  are  probably  the  most  important, 
and,  at  any  rate,  its  secretion,  from  its  taste  and 
color,  is  most  easily  noted.  To  one  acquainted  with 
the  physiology  of  these  organs  the  symptoms  from 
these  various  sources  are  not,  in  general,  difficult  to 
anderstand. 

This  is  not  all.  The  stomach  maintains  a  connec- 
tion, by  sympathy  and  otherwise,  with  all  other  parts 


ON   DYSPEPSY.  205 

of  the  body.  Hence,  diseases  of  other  parts  may 
bring  on  dyspepsy  j  or  this  trouble  in  the  stomach 
may  cause  disturbances  and  derangements  in  various 
parts  of  the  body  and  in  the  mind.  Thus  the  symp- 
toms occurring  in  this  disease  are  increased  in  number 
and  variety. 

Dyspepsy  consists,  then,  in  a  difficulty  or  labor  in 
the  digestion  of  the  food ;  and  this  difficulty  may  be 
various  in  degree.  Its  leading  symptoms  are  oppres- 
sion or  uneasiness  at  the  stomach,  heartburn,  flatu- 
lence, eructation  of  wind,  or  efforts  for  this  purpose, 
regurgitation  of  the  food,  and  sometimes  vomiting.  I 
regard  the  oppression  as  evidence  that  the  digestion  is 
going  on,  though  with  hard  labor.  It  is  not  uncom- 
mon to  see  food  thrown  from  the  stomach,  perfectly 
undigested,  several  hours  after  it  was  swallowed,  where 
there  had  not  been  any  oppression  meanwhile.  Here 
there  would  seem  not  to  have  been  any  effort  to  digest 
the  food.  The  oppression  is  various  in  degree.  It  is 
somewhat  indefinite  as  to  its  seat,  as  all  internal  feel- 
ings are  apt  to  be.  It  is  generally  referred  to  the 
epigastrium,  but  it  often  extends  upward  under  the 
sternum ;  when  connected  with  a  sense  of  flatulence  it 
even  reaches  up  to  the  throat,  with  a  feeling  as  if  it 
30uld  be  relieved  only  by  bringing  up  the  food,  or  some 
wind.  I  will  say  here  that,  in  these  cases,  the  existence 
18 


206  ON   DYSPEPSY. 

of  air  in  the  stomach  is  not  so  certain,  as  it  seems  to 
be.  The  patient  feels  distressed,  and  finds  relief  when 
an  J  wind  is  brought  up ;  and  thence  he  believes  that 
there  is  a  great  body  of  air  pent  up,  which  is  the  cause 
of  his  trouble.  Mj  suspicion  is  that  the  air  does  not 
exist  there  in  any  extraordinary  quantity,  and  that  it 
is  food  which  prompts  the  efforts  he  makes.  If  air  be 
thrown  up  the  relief  is  very  partial,  but  it  is  greater 
and  more  permanent  if  food  be  regurgitated.  It  is, 
therefore,  better  for  the  patient  not  to  make  violent 
efibrts  to  produce  eructation.  Persons,  who  vomit  with 
ease,  will  sometimes  get  relieved  by  thrusting  a  finger 
into  the  fauces.  This  should  not  be  encouraged.  The 
temptation  to  resort  to  this  expedient  is  very  great, 
and  the  frequent  repetition  of  it  is  injurious.  Some 
men  will  indulge  their  appetites  improperly,  relying 
on  relief  in  this  way. 

The  oppression,  or  uneasiness  at  the  stomach,  usu- 
ally follows  a  meal  within  an  hour,  but  occasionally  it 
is  deferred  to  a  later  period.  It  continues  from  one 
to  three  or  four  hours.  There  is  an  uneasiness  or. 
pain,  which  I  hardly  know  how  to  distinguish  from  the 
above,  which  dyspeptics  sometimes  experience,  from 
two  to  four  o'clock  in  the  morning.  This  is  the  period 
when  gouty  persons  are  apt  to  sufier.  As  this  comes 
after  ?.  long  fast,  for  it  will  occur  in  persons  who  do 


ON   DYSPEPSY.  207 

not  eat  supper,  it  cannot  be  regarded  as  a  trouble 
attending  the  act  of  digestion.  It  is  more  probable 
that  it  results  from  some  acrid  matter  left  in  the 
stomach  after  the  entire  conclusion  of  the  digestion. 

Heartburn  is  regarded  as  the  effect  of  some  acid 
in  the  stomach.  It  is  most  noted  when  some  acescent 
food  has  been  taken,  and  may  commonly  be  avoided 
by  abstaining  from  such  food.  But  it  does  not  always 
occur  when  there  is  an  acid  in  the  stomach  ;  for  a  dys- 
peptic will  sometimes  throw  up  a  very  sharp  acid,  when 
he  has  not  had  any  heartburn.  On  the  other  hand, 
I  think  that  you  will  hear  of  this  symptom  from  per- 
sons, who  abstain  almost  entirely  from  acescent  food. 
May  not  these  facts  be  explained  by  the  hypothesis, 
that  there  is  sometimes  a  very  tender  spot  in  the 
mucous  membrane  of  the  stomach,  and  that  the 
smallest  portion  of  acid  may  be  enough  to  irritate 
such  a  spot  ? 

Flatulence  in  the  stomach,  that  is,  air  of  some  kind 
developed  in  that  organ,  is  probably  the  result  of  some 
chemical  change  in  undigested  food.  That  explanation 
does  at  least  satisfy  the  most  common  cases  of  flatu- 
lence in  that  organ.  But,  as  has  been  intimated 
before,  the  sensations  of  the  patient  are  probably 
sometimes  deceptive  as  to  the  existence  of  much  air  in 
the  stomach. 


208  ON   DYSPEPSY. 

Regurgitation  and  vomiting  of  food  occur  much 
more  readily  in  some  subjects  than  in  others.  It  is 
apparently  in  those,  who  have  a  facility  in  performing 
an  act,  which  others  cannot  bring  about  without  great 
effort,  and  that  only  under  the  influence  of  some  pecu- 
liar or  very  powerful  stimulus.  This  peculiar  facility, 
and  its  opposite,  the  great  difficulty  in  bringing  up 
the  contents  of  the  stomach,  are  original  differences 
not  to  be  explained.  Other  things  being  equal,  the 
operations  above  mentioned  are  not  produced  so  much 
by  the  greater  difficulty  of  digestion  in  one  case  than 
in  another,  as  by  a  greater  tenderness  in  some  part  of 
the  stomach  in  some  instances.  Thus,  an  ulceration, 
and,  perhaps,  even  a  slight  one,  in  the  mucous  coat 
of  the  stomach  may  cause  the  regurgitation,  etc.  Where 
vomiting  is  very  frequent,  resisting  all  remedies, 
there  is  good  cause  for  suspecting  organic  disease  of 
the  stomach.  Yet  it  must  not  be  admitted  as  proof 
of  such  a  disease.  The  following  remarkable  history, 
which  I  will  endeavor  to  state  briefly,  wall  support  what; 
I  say.  This  was  a  case  where  a  severe  and  obsti- 
nate dyspepsy  continued  for  several  years,  not  being 
relieved  by  medicine,  nor  by  travelling  in  this  coun- 
try and  in  Europe ;  which  at  last,  while  the  patient 
was  abroad,  terminated  in  daily  vomiting.  The  patient, 
a  lady,  at  length  restricted  herself  to  one  meal  a  day, 


ON  DYSPEPSY.  209 

which  she  took  ordinarily  at  three  o'clock.  She 
seemed  to  throw  up  the  whole  of  this  within  three 
hours,  invariably.  I  was  an  eje-witness  to  the  act 
verj  often.  Of  course  something  was  retained,  as 
she  lived  in  this  state  between  two  and  three  years. 
At  length  she  died  exhausted.  The  first  symptoms 
attending  her  failure  seemed  to  belong  to  the  brain. 
I  called  on  her  in  the  morning,  and  she  had  her  usual 
smile,  and  asked  common  questions ;  but  she  could  not 
remember  what  she  had  said,  or  what  was  said  to  her, 
for  three  minutes.  Within  twenty-four  hours  she 
became  stupid,  and  she  remained  in  this  state  two  or 
three  days,  when  she  expired.  I  mention  these  cir- 
cumstances of  her  death  as  having  some  interest.  It 
was  a  death  simply  from  the  want  of  nutrition.  The 
disease  began  under  circumstances  of  an  aflBiicting  and 
depressing  character.  Time  removed  the  feeling  of 
depression,  and  she  grew  cheerful.  Her  mind  was 
bright  and  active.  She  went  abroad  in  a  carriage  as 
long  as  she  could,  and  never  kept  her  bed  till  the  last 
days  of  her  life.  I  cannot  go  into  all  the  symptoms, 
positive  and  negative.  Suffice  it  to  say  that  there 
were  not  any  physical  signs  of  organic  disease ;  and, 
after  frequent  and  thorough  investigation  of  all  that 
belonged  to  the  case,  I  was  perfectly  satisfied  that 
there  was  not  any  such  disease.  The  autopsy  was 
18* 


210  ON   DYSPEPSY. 

made  by  Dr.  J.  B.  S.  Jackson,  in  the  presence  of 
Dr.  John  Ware,  and  made  with  all  the  precautions 
necessary  to  prove  a  negative.  There  was  not  dis- 
covered any  change  in  the  structure,  or  organization 
of  any  one  part.  It  may  be  proper  to  add  that  the 
patient  belonged  to  a  family,  in  which  some  other 
members  had  remarkable  nervous  diseases,  though 
each  differing  from  the  others.  I  relate  this  case  to 
show  that  we  must  be  cautious  in  deciding  that  there 
is  organic  disease  of  the  stomach,  even  under  the  most 
obstinate  vomiting.  All  I  would  add,  besides  the 
absence  of  physical  signs  in  this  case,  is,  that  there 
was  not  the  physiognomy  of  organic  disease.  There 
was  not  the  sharp  emaciation,  nor  the  degeneration  of 
the  skin,  the  roughness  and  loss  of  its  natural  color, 
which  organic  disease  ordinarily  produces. 

Dyspepsy  is  most  commonly  attended  by  costive- 
ness,  or  at  least  by  slowness  in  the  bowels ;  indeed, 
the  difficulty  in  the  bowels  often  precedes,  if  it  does 
not  cause,  that  in  the  stomach.  It  is  not  so  easy  to 
manage  the  case  w^hen  the  costiveness  is  added  to  it. 
Instead  of  costiveness,  diarrhoea  occurs  in  some  in- 
stances, or  the  two  alternate.  The  diarrhoea  is  not 
constant,  but  follows  the  use  of  indigestible  articles, 
especially  of  those  which  are  acid,  or  acescent.  To  the 
symptoms  belonging  to  the  alimentary  canal  and  its 


ON   DYSPEPSY.  211 

appendages,  are  added  occasionally  some  in  other 
organs.  Such  are  headache,  vertigo,  palpitation  of 
the  heart,  or  uneasy  sensations  about  that  vital  organ, 
and  pain  in  the  breast,  at  various  points.  Likewise 
the  spirits  are  depressed  in  many  instances ;  and 
sometimes  you  see  a  dyspeptic  who  becomes  quite 
incapable  of  intellectual  labor.  Some,  who  study 
their  symptoms,  and  constantly  watch  the  effects  of 
food  and  remedies,  become  notional,  and  often  very 
unhappy.  On  this  account  the  physician  may  be 
obliged  to  give  up  a  close  inquiry  into  the  course  of 
the  disease. 

After  investigating  the  history  of  a  dyspeptic,  you 
may  find  that  the  principal  remote  cause  of  this 
disease  was  something  which  has  passed  away,  but 
has  left  a  permanent  effect.  You  may  strive  to 
remove  the  effect,  but  the  cause  is  beyond  your  reach. 
Much  more  frequently  you  find  that  the  remote  cause 
or  causes  continue  to  exist.  In  such  cases  you  should 
of  course  try  to  remove  the  effects ;  but  it  is  of  the  first 
importance  to  remove,  or  to  counteract  the  causes. 
Sometimes  this  is  beyond  the  power  of  man,  though 
nature  may  do  it  in  due  time ;  but  in  the  largest 
number  of  instances  it  may  be  done,  if  the  patient  is 
obedient.  Then  it  becomes  necessary  to  ascertain  in 
each  case  what  pauses  have  produced  the  disease,  and 


212  ON  DYSPEPSY. 

for  this  purpose  it  is  often  requisite  to  get  a  history 
of  the  patient's  life. 

Prominent  among  the  remote  causes  in  question  are 
eiTors  of  diet.  These  errors  ha^re  regard  to  the 
quantity,  the  quality,  or  the  frequency  of  meals.  As 
to  quantity,  —  one  cannot  say  how  much  food  any 
individual  may  require,  or  can  bear.  There  are 
instances,  in  which  it  is  quite'  clear  that  the  patient 
does  not  take  enough  for  his  support.  There  are 
vastly  more,  in  which  he  takes  too  much.  If  one 
takes  more  food  than  others  at  the  same  table,  and 
no  other  obvious  cause  for  his  dyspepsy  can  be  dis- 
covered, we  may  fairly  conclude  that  he  takes  too 
much. 

In  respect  to  the  quality,  it  would  occupy  too  much 
space  to  point  out  all  possible  errors.  Yet  in  practice 
it  is  not  very  difficult  to  decide  this  point.  Has  your 
patient  lived  on  the  coarsest  vegetable  food,  and  that 
badly  prepared,  you  will  not  doubt  that  there  has  been 
a  fault  in  his  diet  as  to  quality.  You  will  as  little 
doubt  it  as  to  one,  who  has  lived  entirely  on  the  most 
savory  articles,  with  the  addition  of  the  strongest 
condiments.  Nor  is  there  much  difficulty  in  the 
decision,  when  the  errors  have  been  less  glaring. 

As  to  the  frequency  of  meals,  few  adults  can  take 
more  than  three  in  a  day  without  injury.     Children 


ON  DYSPEPST.  213 

can  eat  more  frequently ;  but  between  eighteen  and 
twentj-five  you  will  find  many  dyspeptics,  who  get 
relief  on  giving  up  their  childish  habits.  These  and 
other  remarks  on  diet  are  not  shown  to  be  groundless, 
because  many  persons  disregard  them  with  impunity. 
The  question  is  not  whether  certain  practices  are 
always  injurious,  but  whether  they  are  not  often,  or 
sometimes  so. 

Next  among  the  causes  of  dyspepsy  may  be  men- 
tioned a  sedentary  life,  or  a  neglect  of  bodily  exercise. 
Prom  these  causes  the  student  and  the  shoemaker  are 
equally  liable  to  suffer.  The  evil  may  be  greater, 
perhaps,  to  one  who  undergoes  much  intellectual 
labor;  but  that  is  not  very  certain,  unless  that  labor  is 
attended  by  great  responsibility,  or  by  anxiety  as  to 
its  results.  Anxiety  alone  very  often  induces  dys- 
pepsy. You  see  this  in  young  men  entering,  on  the 
business  of  life.  I  have  witnessed  it  equally  in  young 
physicians  and  young  mechanics.  Whenever  the 
mind  and  the  heart  are  too  much  devoted  to  one 
object,  the  digestion  is  apt  to  fail.  The  same  conse- 
quence follows  from  a  mere  routine  in  business, 
where  the  attention  must  be  constantly  maintained, 
without  any  real  interest  in  its  object. 

You  find,  then,  your  dyspeptics  among  those  who 
work  in  the  houses,  and  not  in  the  fields,  who  endure 


214  ON  DYSPEPST. 

great  responsibility,  or  great  anxiety,  or  who  work  in 
a  treadmill  for  a  mere  maintenance  ;  among  those  who 
are  half-starved,  and  among  those  who  gormandize 
and  drink  and  smoke  ;  and  among  the  dissolute  and 
licentious  ;  so  that  the  disease  comes  to  the  wise  and 
to  the  foolish,  to  the  best  and  to  the  worst  of  men. 

A  young  clergyman,  or  a  young  schoolmaster,  may 
call  on  you,  and  tell  a  story,  of  which,  when  you  have 
heard  the  introduction,  you  might  tell  him  all  that 
follows.  It  is  this  :  He  worked  on  his  father's  farm 
till  his  eighteenth  or  twentieth  year,  and  then  deter- 
mined to  get  an  education.  He  crammed  himself 
with  Latin  and  Greek,  so  as  to  get  into  college  in  two 
years.  While  doing  this  his  head  began  to  suffer,  and 
he  became  costive ;  but  he  thought  these  temporary 
evils,  and  sought  relief  by  salts,  or  other  laxatives. 
He  entered  college,  studied  hard,  and  his  stomach 
began  to  complain.  If  not  at  college,  this  increase  of 
trouble  came  on  soon  after  he  engaged  in  his  profes- 
sional studies ;  and,  perhaps,  headache  also.  If  your 
patient  be  a  clergyman,  you  probably  find  that  he  held 
out  till  he  was  ordained,  but  soon  afterwards  he  found 
that  the  duties  he  had  undertaken  were  too  heavy  for 
him.  Then  his  parish  were  alarmed,  and  he  became 
the  object  of  sympathy.  All  began  to  discuss  the 
nature  of  his  disease,  its  causes,  and  the  remedies 


ON   DYSPEPST.  215 

appropriate  to  it.  Each  kind  matron  pressed  her 
favorite  medicine-  upon  him,  and  all  besought  him  to 
avoid  getting  cold.  I  could  add  to  the  story,  but  that 
is  enough. 

In  the  treatment  of  a  dyspeptic,  then,  more  than 
of  most  other  invalids,  it  is  the  first  object  to  ascer- 
tain the  remote  causes  of  the  disease  in  his  case.  To 
this  end  you  must  get  a  brief  history  of  his  life.  This 
requires  some  cross-questioning ;  for  the  patient  will 
often  hold  back  important  facts,  either  because  he  re- 
gards them  as  unimportant,  or  because  they  are  such 
as  he  does  not  wish  to  disclose.  If  you  suspect  the 
last-named  difiiculty,  it  is  well  to  say  to  him  that  you 
wish  to  know  whether  he  has  had  any  secret  causes 
of  anxiety  or  trouble  ;  that,  if  so,  it  is  enough  for  him 
to  make  a  general  answer,  that  you  would  rather  not 
have  the  charge  of  his  secrets.  You  will  have  the 
best  chance  of  aiding  your  patient,  if  you  can  keep 
him  under  your  eye  and  under  your  care  for  a  while, 
so  as  to  ascertain  his  character  and  habits,  and  so  as 
to  educate  him  as  to  his  mode  of  life.  In  going  over 
the  history  of  his  life  from  day  to  day,  you  may  sat- 
isfy yourself  and  make  him  realize  what  are  the 
errors  of  his  ways ;  that  he  may  be  convinced  that  a 
good  life  will  lead  to  health  ;  that  he  must  not  sin  for 
a  week,  and  seek  absolution  at  the  end  of  it  by  the  aid 


216  ON   DYSPEPSY. 

of  the  apothecary.  In  this  last  course  such  a  man 
loses  ground  constantly. 

In  many  instances,  instead  of  prescribing  a  medi- 
cine, I  have  found  it  necessary  to  give  my  dyspeptic 
patient  a  moral  lecture ;  and  that,  even  though  he 
wore  a  black  coat.  My  lecture  has  indeed  most  often 
had  reference  to  sensual  indulgences  :  but  sometimes 
it  has  turned  upon  points  of  a  very  different  charac- 
ter. Not  unfrequently  I  have  had  to  descant  upon 
the  evils  and  the  impropriety,  if  not  the  sin,  of  over- 
conscientiousness  ;  of  too  great  an  anxiety  to  do  right, 
and  of  distressing  regrets  from  the  fear  of  having 
erred,  unintentionally,  in  some  minute  particular.  In 
this  morbid  state  a  man  may  waste  his  present  hours 
m  lamenting  the  waste  of  minutes  in  time  past. 

But  while  it  is  necessary  to  have  reference  to  the 
moral  state  of  the  dyspeptic,  and  to  advise  him  how 
to  gain  a  control  over  his  feelings,  this  is  not  all. 
You  must  direct  him  as  to  diet,  exercise,  etc.,  and 
must  prescribe  drugs,  so  far  as  they  are  likely  to  be 
beneficial  to  him.  I  refer  mostly  to  the  proper  phys- 
ical benefit  to  be  derived  from  drugs  ;  but  there  is  a 
class  of  patients,  over  whom  you  cannot  maintain  any 
control,  unless  you  indulge  them  in  some  medicine. 
For  their  own  good,  then,  they  should  have  some  safe 
article,  such  as  may  be  useful ;  but  take  care,  in  doing 


ON   DYSPEPSY.  217 

this,  to  have  regard  to  the  patient  onlj,  arid  not  your 
own  glory. 

In  deciding  on  the  diet,  I  would  first  ascertain 
whether  the  patient  has  an  appetite  for  food.  The 
seaman  finds  his  rudder  of  no  avail,  unless  there  is 
wind  enough  to  give  his  ship  headway.  It  is  of  little 
use  to  direct  what  should  be  eaten,  when  the  patient 
does  not  want  to  eat  anything.  One  must,  then,  make 
a  choice  among  difficulties,  and  let  •  the  patient  have 
that,  which  is  least  noxious,  among  those  things  which 
he  consents  to  swallow.  Indeed,  in  such  a  case,  we 
have  to  consider  whether,  by  some  evacuant,  or  by 
some  tonic,  we  cannot  bring  back  the  appetite.  If 
there  be  an  appetite,  the  diet  for  most  dyspeptics 
should  consist  of  animal  food,  farinaceous  articles  in 
their  purest  state,  and  butter.  I  know  that  this  last 
article  is  not  thought  so  well  of  by  all  mankind,  as  it 
is  by  me.  Every  little  boy  knows  it  has  a  bad  name ; 
and,  if  bad  in  quality,  or  excessive  in  quantity,  it  will 
do  harm.  But  of  this  I  feel  assured,  that,  where  fari- 
naceous substances  will  become  acid  in  the  stomach 
if  taken  alone,  they  are  less  likely  to  become  so  if 
taken  with  good  butter.  Also,  it  adds  to  the  satisfac- 
tion of  the  appetite,  and  to  the  nutrition,  very  much 
more  than  in  proportion  to  its  quantity.  In  other 
words,  less  bread  will  answer  the  purpose,  if  butter  be 
19 


218  ON   DYSPEPSY. 

added  to  it.  The  animal  food  is  valuable  because  it  is 
easier  of  digestion  than  vegetable  food,  while  it  is 
usually  most  agreeable  to  the  taste.  Add,  also,  that 
it  does  not  produce  acidity,  nor  flatulence ;  and  it  is 
where  these .  symptoms  exist,  that  we  must  hold  to 
the  most  rigid  diet.  You  will  remark  that  the  arti- 
cles I  have  mentioned  may  be  called  dry,  in  opposi- 
tion to  those  which  are  succulent,  and  which  com- 
monly contain  much  water  and  saccharine  matter. 
Those,  who  suffer  from  acidity,  must  avoid  vegetable 
acids,  and  acescent  substances,  of  which  sugar  is  one 
of  the  worst.  Such  patients  should  also  be  very  abste- 
mious in  the  use  of  liquids,  as  these  promote  acidity. 

Some  condiments  must  be  allowed;  at  least  com- 
mon salt.  If  other  condiments  be  required  by  the 
habits  of  the  patient,  or  because  the  sufferings  from 
flatulence  are  great,  I  think  you  will  find  the  safest 
to' be  those  in  most  common  use,  mustard  and  pepper, 
especially  the  black  pepper.  The  more  aromatic 
spices,  such  as  cloves,  are  positively  injurious  to  many 
persons.  They  paralyze  the  stomach ;  not  in  the 
strict  sense  of  the  word,  but  they  stop  its  action 
upon  the  food. 

If  costiveness  be  combined  with  the  dyspepsy,  it  is 
very  desirable  to  allow  the  use  of  some  laxative  food. 
But  this  food  is  just  such  as  I  have  pointed  out  as 


/*k« 


ON  DYSPEPSY.  219 

hurtful  to  many  patients  suffering  from  this  disease.  It 
is  acescent  and  flatulent.  Indeed,  it  would  seem  that 
those  parts  of  the  food,  which  are  not  digested,  are  those 
which  exercise  the  most  influence  upon  the  bowels. 

What  shall  we  do,  then,  with  the  dyspeptic  who  is 
costive  ?  To  which  shall  we  pay  most  regard  in  ar- 
rano^ing  the  diet. —  to  the  stomach,  or  to  the  bowels  ? 
I  reply,  to  the  stomach.  You  may  subject  that  to 
some  slight  inconveniences  occasionally ;  but  it  must 
not  be  annoyed  habitually  for  the  sake  of  the  bowels. 
Keep  that  in  good  order,  and,  as  the  smaller  evil, 
employ  artificial  means  for  the  regulation  of  the 
bowels.  Those  means  must  be  the  mildest  which  will 
effect  the  object ;  and  we  must  find  out  by  trial  what 
these  are  in  each  particular  case. 

It  is  best  to  use  injections  into  the  bowels,  if  these 
will  answer  the  purpose.  They  will  do  so,  if  the 
peristaltic  motion  is  sufficiently  active,  and  if  the  fail- 
ure occurs  in  the  rectum  only.  Then,  we  should 
administer  from  one  to  two  gills  of  cold,  or  cool  water. 
If  this  be  insufficient,  we  may  add  soap  and  oil  to  the 
water ;  but  very  stimulating  articles  should  not  be 
employed  for  this  purpose  habitually.  The  rectum 
must  be  treated  with  caution.  The  comfort  of  life  is 
greatly  impaired  by  any  injury  of  this  part ;  a  truth, 
which  it  would  be  well  if  all  men  were  aware  of  early 


220  ON  DYSPEPSY. 

in  life.  If  the  injections  be  insufficient,  we  must  try 
medicines  by  the  stomach.  In  cases  where  the  dys- 
pepsy  is  not  severe,  we  may  often  do  well  with  Seidlitz 
powders,  or  Congress  water.  One  of  these  may  be 
taken  every  morning  before  food,  in  such  quantity  as 
is  found  necessary  to  give  one  dejection.  But  for 
some  persons,  especially  those  who  take  very  little 
food,  it  is  found  more  advantageous  to  employ  the  lax- 
ative medicine  every  other  day.  The  quantity  of 
liquid  in  the  saline  articles  above  mentioned  is  an 
objection  to  them  in  some  instances  of  severe  dys- 
pepsy.  In  others,  these  articles  are  ineffectual.  We 
should,  then,  seek  such  as  are  more  efHcient,  and  less 
bulky.  If  we  must  use  them,  it  is  better  to  give 
them  in  such  small  doses,  as  that  they  may  operate 
very  slowly ;  such  as  will  rather  crawl  through  the 
bowels,  than  push  through  them.  For  the  most  part  it 
is  better  to  combine  two,  or  more  articles,  than  to  give 
one  alone.  An  article  of  this  character  may  be  used 
under  the  name  of  a  dinner-pill ;  and  the  name  helps 
take  off  the  odium  of  a  cathartic  medicine.  A  com- 
bination may  be  made  up,  after  trial,  to  suit  each 
case.  You  may  introduce  a  very  powerful  article  into 
such  a  pill,  in  a  very  minute  dose.  Strychnia  ia 
employed  in  this  way  at  the  present  day,  and  my  triak 
of  it  have  led  me  to  think  well  of  it.     But  it  should 


ON   DYSPEPSY.  221 

be  given  in  a  very  small  dose,  from  a  twelfth  to  a 
twenty-fourth  part  of  a  grain.  It  is  very  essential 
that  it  should  be  equally  distributed  through  the  mass, 
in  the  compound  into  which  it  enters.  To  effect  this, 
a  grain  of  the  strychnia  may  first  be  mixed  very  inti- 
mately with  a  quarter  part  of  the  mass,  and  then  this 
portion  may  be  mixed  very  thoroughly  with  the  whole 
of  it.  A  dinner-pill  may  be  taken  every  day  soon 
after,  or  just  before  dinner,  as  the  patient  may  prefer. 
He  should  be  apprized  that  you  want  only  a  natural 
dejection,  and  that  the  medicine  operates  best,  when  a 
nurse  would  say  that  it  had  not  operated  at  all.  In 
the  use  of  such  an  article,  one  should  not  be  troubled 
if  on  some  days  it  fails  to  have  an  effect.  There  are 
persons  for  whom  one  such  pill  a  day  is  insufficient, 
and  another  must  be  allowed  either  in  the  morning  or 
the  evening.  The  patient  should  be  informed  when  his 
dinner-pill  contains  a  powerful  article,  though  in  a 
small  dose ;  and  he  should  be  warned  never  to  take  two 
at  a  time,  nor  even  one,  oftener  than  he  is  directed.  If, 
happily,  the  case  will  admit  the  use  of  laxative  food, 
we  may  dispense  with  all  these  medicines.  In  respect 
to  this  point,  and  others  for  obviating  costiveness,  I 
refer  you  to  the  letter  on  constipation. 

It  was  said  above  that  animal  food  was  best  adapted 
to  the  dyspeptic ;  but  we  must  beware  of  universal 
19* 


222  ON   DYSPEPSY. 

propositions  and  assertions.  You  will  find  some  in- 
stances,  in  which  animal  food  cannot  be  digested,  or 
not  without  much  difficulty ;  but  in  which  bread,  rice, 
and  other  vegetable  food,  not  acid,  are  both  grateful 
and  borne  with  ease.  I  cannot  tell  you  how  you  are 
to  know,  before  trial,  in  what  cases  this  peculiarity 
occurs.  It  is  not,  I  think,  so  common  in  men  as  in 
women ;  and  I  believe  that  it  is  not  found  in  persons 
of  sedentary  habits,  whether  scholars  or  artisans. 

What  shall  I  drink,  is  a  question  from  a  dyspeptic 
not  easily  answered.  I  believe  I  have  said  that  much 
liquid  is  bad  for  such  a  one.  In  cases  at  all  severe  I 
usually  restrict  the  patient  to  three  gills  a  day ;  an 
amount  much  less  than  he  probably  craves.  But 
what  shall  this  be  ?  Water  answers  very  well  in  some 
instances,  and  it  is  free  from  the  objections,  to  which 
other  beverages  are  liable.  But  it  is  too  flat  for  most 
persons.  Let  it,  then,  be  tea,  or  coffee,  or  cocoa. 
Chocolate,  and  other  preparations  of  cocoa,  give  trouble 
to  some  persons,  and  especially  when  they  are  dys- 
peptic. They  cause  oppression,  or  acidity  in  the 
stomach,  or  headache.  If  the  use  of  them  for  a  few 
days  do  not  reconcile  the  stomach  to  them,  they  should 
be  omitted.  Again,  tea  and  coffee  do  not  suit  some 
individuals  of  the  nervous  class,  and  it  is  rather  fash- 
ionable to  decry  them.     There  is  a  notion  that  what 


ON   DYSPEPSY.  223 

13  agreeable  must  be  bad ;  but  I  hold  just  the  contrary 
doctrine,  unless  when  the  patient  is  induced  to  take 
too  much  J  because  it  is  agreeable.  It  is  clearly  one 
recommendation  of  any  article  that  it  is  agreeable ; 
and,  if  an  objection  is  made  to  such  an  article,  the 
burden  of  proof  should  be  thrown  upon  him  who  ob- 
jects to  it.  Tea  and  coflfee  do  sometimes  produce 
inconvenience.  They  occasion  watchfulness,  or  uneasy 
sleep  in  the  night;  also,  tremors  of  the  hands  and 
palpitation  of  the  heart,  especially  when  taken  without 
any  solid  food.  Let  persons  who  suffer  in  these  ways 
use  the  tea  or  coffee  w^eak ;  and,  if  they  still  suffer, 
let  them  give  up  the  favorite  articles.  But  do  not 
oblige  others  to  give  them  up  on  this  account.  I  have 
watched  very  carefully,  and  have  never  had  reason  to 
believe  that  these  articles  produced  evils  at  a  distant 
period ;  it  is  at  the  time,  within  the  day  when  they 
are  used,  that  the  evils  come,  if  they  come  at  all. 

Persons  who  have  been  accustomed  to  wine,  or 
malt  liquor,  often  find  these  salutary  once  or  twice  a 
day.  In  a  large  proportion  of  dyspeptics  they  become 
acid  in  the  stomach ;  and  on  this  account,  not  because 
they  are  stimulant,  we  are  obliged  to  forbid  them.  In 
such  cases,  where  we  want  the  stimulant,  and  wish  to 
avoid  the  acidity,  brandy,  or  some  other  alcoholic 
liquor,  may  be  used.     Whichever  is  allowed,  wine  or 


224  ON   DYSPEPSY. 

spirit,  it  is  proper  to  prescribe  the  quantity.  In  gen- 
eral, for  an  adult,  a  gill  of  good  sherry  in  a  day,  or  a 
quarter,  or  a  third  of  that  quantity,  of  good  brandy, 
will  suffice ;  though  we  must  sometimes  increase  the 
doses. 

I  am  fully  aware  of  the  terrible  evils,  which  may 
arise  from  the  excessive  indulgence  in  the  articles 
above  mentioned ;  and  I  have  heard  it  said  that  phy- 
sicians have  made  drunkards  by  allowing  the  use  of 
them.  This  is  a  matter  to  be  considered  gravely.  So 
I  thought  before  the  days  of  temperance  reform.  I 
advise  you  to  consider  it  in  every  case,  where  you 
think  of  prescribing  articles  capable  of  producing  in- 
toxication. This  should  be  done  especially  as  to  the 
alcoholic  articles,  as  the  temptation  is  to  use  them, 
mixed  with  water,  stronger  and  stronger.  Accord- 
ingly, I  would  never  order  them  to  one,  whom  I  sus- 
pected to  be  deficient  in  prudence  and  self-control. 
But,  keeping  these  things  in  mind,  I  have  often  directed 
the  use  even  of  brandy.  In  doing  this,  I  have  been 
in  the  habit  of  saying  to  the  patient,  ''  If  I  ever  hear 
of  your  indulging  to  excess  in  the  use  of  this,  or  any 
similar  article,  I  will  call  on  you  and  exhort  you  to 
stop."  In  one  instance,  and  only  one,  in  the  course 
of  a  long  life,  have  I  been  called  upon  to  redeem  my 
pledge.     This  was  in  the  case  of  a  worthy  lady,  some 


ON   DYSPEPSY.  225 

twenty  years  after  I  had  directed  the  measured  use  of 
brandy.  At  my  request  she  immediately  gave  up  the 
use  of  all  spirituous  and  fermented  liquors,  and  I  have 
reason  to  believe  that  she  never  resumed  them.  I  do 
not,  then,  call  the  risk  very  great  of  such  prescrip- 
tions, when  made  with  proper  caution.  In  regard  to 
the  benefit  in  some  cases  of  dyspepsy,  and  in  various 
other  cases,  I  have  not  any  doubt.  And,  that  I  may 
tell  the  whole,  let  me  say,  that  I  have  repeatedly  seen 
very  great  benefit  from  giving  wine  to  young  children. 
The  benefit  has  been  particularly  marked  in  some 
children  struggling  feebly  through  the  period  of  den- 
tition ;  and  I  can  name  some  to  whom  I  had  made 
this  prescription  more  than  forty  years  ago,  among 
whom  not  one  has  shown  any  peculiar  fondness  for 
wine  in  subsequent  years.  I  exhort  all  young  people 
in  health  not  to  adopt  the  practice  of  drinking  wine. 
I  deprecate  everything  which  shall  tend  to  intemper- 
ance, and  I  believe  that  many  men  sufier  from  the 
use  of  wine  and  spirits  even  in  a  moderate  way.  But 
I  love  to  tell  the  truth,  even  when  it  is  unfashionable. 
I  believe  that  very  many  persons  are  benefited  by  the 
juice  of  the  grape,  and  I  choose  to  say  so.  Moreover, 
I  believe  that  persons  disposed  to  intemperance  are 
not  to  be  restrained  from  indulging  their  vicious  pro- 
pensity,  by  the   abstinence   of  their  more   prudent 


226.  ON  DYSPEPSY. 

neighbors.  These  are  opinions  at  which  I  have  arrived 
after  much  attention  to  the  subject.  Others,  men  of 
the  first  respectability,  disagree  with  me  entirely.  Let 
it  be  so  ;  but  I  trust  that  the  majority  will  agree  that 
it  is  possible  for  them  to  be  in  the  wrong,  and  not 
insist  upon  controlling  the  minority  on  this  subject, 
any  more  than  as  to  the  question  whether  animal  or 
vegetable  food  is  the  most  wholesome.  It  is  not  a 
settled  point  whether  woollen  clothing  should  be  worn 
next  the  skin.  Shall  a  minority  be  obliged  to  submit 
to  the  majority  in  this  matter  ? 

I  have  made  some  remarks  in  favor  of  moderation 
in  eating,  but  something  definite  may  be  expected  on 
this  head.  I  believe  that  Mr.  Abernethy  limited  his 
patients  to  four  ounces  of  meat  at  a  meal.  I  would 
as  soon  prescribe  to  every  dyspeptic  to  wear  a  coat  of 
a  certain  size  and  shape,  as  to  direct  the  food  in  this 
way.  This  matter  of  more  or  less  is  difiicult  to  settle, 
and  yet  every  man  of  common  sense  knows  what  is 
much  and  what  is  little  for  himself  at  a  meal.  Every 
man  can  tell  you  whether  it  is  raining  hard  or  not ; 
and  yet  any  one  would  stare  at  you  if  you  should  ask, 
in  such  a  case,  how  much  •  it  must  rain  in  an  hour  for 
you  to  say  that  it  is  raining  hard.  As  to  eating,  a 
man  may  compare  himself  with  those  about  him,  and 
with  himself,  when  in  health,  to  decide  whether  he  is 


ON   DYSPEPSY.  22T 

moderate  or  not.  But  if  you  must  prescribe  the 
quantity,  direct  the  patient  with  precision,  for  two  or 
three  days,  how  much  to  take,  and  then  judge  by  the 
effects  whether  your  allowance  is  too  much  or  too 
little.  You  need  not  have  the  food  weighed ;  it  will 
suffice  if  you  look  at  the  patient's  thumb  or  finger, 
and  let  him  judge  by  that ;  allowing  him,  for  instance, 
as  much  meat  as  two  or  four  fingers,  and  twice  as 
much  bread  at  his  dinner.  One  rule  you  may  always 
give,  to  be  regarded  over  all  others,  namely,  not  to  eat 
quite  so  much  as  the  appetite  demands.  This,  indeed, 
must  not  be  applied  to  a  man  without  appetite. 

1  must  now  add  something  respecting  bodily  exer- 
cise. The  importance  of  this  is  so  familiar  to  my  own 
mind,  that  I  feel  as  if  I  should  be  giving  you  truisms 
in  stating  my  views  on  the  subject.  I  have  said 
already  that  the  dyspeptics  are  foutid  mostly  among 
those  who  live  in  the  house.  There  are  men,  of  the 
true  Dutch  breed,  who  can  live  in  the  house  fifty  years 
without  finding  out  what  dyspepsy  is.  But  such  per- 
sons could  hold  out  twenty  years  longer,  if  they  would 
take  exercise  abroad.  I  do  not  say  this  at  a  guess ; 
for  I  have  seen  it  tried,  and,  if  it  would  not  take  up 
too  much  time,  I  would  state  the  cases.  At  any  rate, 
the  dyspeptic  must  take  exercise  abroad;  and,  if  he 
says  he  is  too  weak,  this  only  proves  more  strongly 


228  ON   DYSPEPSY. 

the  necessity  of  obeying  the  law.  If  he  can  only 
walk  to  the  end  of  his  street,  or  if  he  can  walk  only 
five  rods,  let  him  do  that  as  often  as  he  can,  and  his 
strength  will  increase.  If  he  can  take  a  good  walk^ 
let  him  go  out  at  least  twice  in  the  day.  If  possible, 
let  him  have  some  object,  but  not  such  as  to  burden 
him.  Or,  as  far  as  his  strength  will  permit,  let  him 
combine  amusement  with  his  exercise.  At  the  com- 
mencement of  the  treatment  it  is  often  expedient  to 
send  the  patient  on  a  journey.  In  doing  this  he 
should  be  cautioned  to  adhere  to  rules  as  to  diet,  so 
far  as  possible.  Likewise,  he  should  take  some  exer- 
cise on  foot  daily.  He  should  not  be  on  the  road 
more  than  four,  or  six  hours  iii  the  day.  He  should 
get  all  the  amusement  which  his  strength  will  permit. 
He  should  give  proper  time  for  sleep,  and  should  not 
be  hurried  off  in  the  morning.  Our  railroads  give  us 
great  conveniences,  but  do  not  always  allow  the  invalid 
as  much  accommodation,  as  could  be  had  before  they 
w^ere  built.  I  have  referred  to  walking  as  one  mode  of 
exercise,  and,  if  the  patient  can  endure  it,  this  should 
never  be  omitted ;  but  those  to  whom  it  is  convenient 
should  also  ride  on  horseback.  This  is  an  excellent 
mode  of  exercise  anywhere,  but  it  is  particularly 
valuable  to  men  of  business  in  a  city,  to  whom  it  ia 
important  to  make  the  most  of  a  single  hour. 


ON   DYSPEPSY.  229 

Next,  as  to  the  medicinal  treatment.  I  have 
already  spoken  of  the  remedies  for  constipation,  or 
slow  bowels.  One  of  the  most  obvious  requisites  for 
the  dyspeptic,  at  first  view,  is  a  tonic.  Exercise  is 
a  tonic  above  all  medicinal  articles;  but  these  also 
may  be  employed  with  advantage  in  many  instances. 
A  faintness,  or  sinking  at  the  stomach,  .sometimes 
even  a  painful  faintness  is  among  the  annoying  symp- 
toms of  dyspepsy.  For  this,  the  sub-nitrate  of  bis- 
muth is  a  very  valuable  remedy.  It  is  not  always 
successful,  but  often  operates  like  a  charm.  But  it 
will  be  found  best  to  intermit  the  use  of  it  after  two 
or  three  weeks.  It  may  be  given  in  doses  of  five 
grains  three  times  a  day.  This  dose  is  enough  for 
any  one,  and  it  is  very  rarely  too  much.  The  mode 
of  giving  it  is  not  unimportant.  As  it  is  a  metallic 
substance,  it  is  most  convenient  to  give  it  in  some 
viscid  liquid,  though  it  can  be  taken,  out  of  a  teaspoon, 
with  a  little  water.  We  commonly  use  a  syrup,  when 
we  want  a  viscid  liquid  for  medicine  ;  but  the  stomach 
of  the  dyspeptic  does  not  bear  this  article  very  well. 
It  is  better  to  use  gum  acacia ;  and  it  is  most  conve- 
nient to  mix  the  bismuth  with  an  equal  quantity  of 
this  gum  in  powder,  and  then  to  direct  the  patient  to 
take  it,  mixed  with  a  few  drops  of  water.  This  is 
better  than  to  put  the  medicine  into  the  form  of  pills. 
20 


230  ON   DYSPEPSY. 

When  the  appetite  is  deficient,  a  vegetable  sub-tonic 
may  be  given.  There  are  abundance  of  these.  I  am 
in  the  habit  of  using  one,  which  may  not.  however,  be 
better  than  many  others.  I  direct  an  ounce  of  casca- 
rilla  bark  bruised,  and  from  two  to  four  drachms  of 
quassia  rasped,  to  be  mixed  with  a  pint  of  boiling 
water.  This  mixture  should  stand-  for  three  or  four 
hours  ;  the  liquid  should  be  strained  off,  and  to  this 
should  be  added  one  or  two  ounces  of  the  tincture  of 
cardamoms;  or,  if  there  be  any  diarrhoea,  tincture 
of  cinnamon.  Of  the  liquid  thus  prepared,  the  patient 
should  take  one  to  two  tablespoonfuls  three  times  a 
day.  When  the  object  is  to  operate  on  the  whole 
system,  especially  for  anaemic  patients,  some  prepara- 
tion of  iron  is  preferable.  The  preparations  of  iron 
are  very  numerous,  and  you  may  select  the  one  best 
adapted  to  the  circumstances.  The  compound  mixture 
of  iron  is  a  very  valuable  one,  in  doses  of  from  one  to 
two  tablespoonfuls  three  times  a  day.  One  more 
agreeable  to  the  taste  is  the  citrate  of  iron,  in  doses  of 
five  grains  or  more. 

Many  dyspeptics  gain  very  much  by  visiting  min- 
eral springs,  particularly  those  at  Saratoga.  After 
using  the  Congi^ess  water  at  that  place,  for  a  short 
time,  the  patient  is  apt  to  believe  himself  well.  In 
his  third  week  he  eats  what  he  pleases,  and  as  much 


ON   DTSPEPSY.  231 

as  he  pleases,  and  no  evil  ensues.  But  all  this 
depends  on  the  daily  use  of  the  water.  He  leaves  the 
springs,  and  when  he  reaches  home,  perhaps  the  first 
evening,  he  indulges  in  a  supper.  The  next  morning 
he  awakes  with  a  crowded  head,  or  a  bad  taste  in  his 
mouth,  and  finds  that  he  is  no  longer  at  Saratoga. 
He  complains  of  the  bad  air  of  the  citj;  but  the 
truth  is,  he  did  not  get  his  water  the  morning  before, 
and  the  gutter  has  not  been  washed  out.  Neverthe- 
less, with  proper  prudence,  much  may  be  gained  at 
the  watering-place.  The  patient  should  be  moderate 
in  his  diet  when  he  is  there,  and  be  especially  careful 
to  avoid  the  errors  above  mentioned  on  his  return 
home. 

Finally,  many  dyspeptics  never  get  perfectly  well ; 
yet  they  recover  enough  to  enjoy  life,  if  they  will 
adhere  to  the  restraints  and  to  the  efforts  which 
experience  shows  to  be  necessary.  There  is  one 
comfort,  however.  Not  unfrequently,  between  sixty 
and  seventy  years  of  age,  men  get  over  this  complaint, 
and  can  indulge  in  the  use  of  food,  which  they  had 
not  been  able  to  bear  for  twenty  or  thirty  years. 
This  is  not,  I  think,  so  often  true  among  women,  as 
in  our  sex. 


LETTER    XIII. 


LARLY   OF   THE   CCECUM   AND    COLON. 

This  letter  will  be  on  diseases  of  the  intestines. 
You  will  not  suppose  that  I  shall  embrace  in  so  small 
a  compass  even  a  brief  account  of  all  those  diseases. 
I  shall  present  to  jou  some  physiological  and  patho- 
logical views  in  respect  to  the  intestinal  canal,  which 
I  have  long  entertained,  and  which  I  think  have  aided 
me  in  practice.  I  make  no  claim  to  originality  as  to 
these  views,  or  doctrines;  for,  in  truth,  I  cannot 
remember  whether  I  have  derived  them  from  any  one 
else,  or  not.  If  you  get  to  have  just  notions  of  the 
simpler  diseases  of  this  important  part  of  the  organic 
system,  you  will  be  prepared  to  study  with  greater 
ease  its  more  complicated  affections.  I  shall  after- 
wards treat  more  particularly  of  two  diseases  of  the 
coecum  and  colon. 

Our  knowledge  in  regard  to  the  functions  of  the 
stomach  is  not  so  full,  nor  so  precise,  as  we  could 


ON   DISEASES   OF  THE   INTESTINES.  233 

wish ;  but  our  knowledge  of  the  functions  of  the  in* 
testines  is  still  more  deficient.  We  know,  indeed, 
that  the  chyme,  or  mass  poured  out  from  the  stomach 
into  the  duodenum,  is  there  mixed  with  the  bile  and 
pancreatic  juice ;  that  it  is  then  carried  slowly  through 
the  small  intestine ;  and  that,  in  its  passage,  the 
chyle  is  taken  up  by  the  lacteals.  It  would  seem, 
at  first  view,  that  nothing  remained  but  to  carry  off 
the  refuse,  or  faecal  part  of  this  mass.  But  there  is 
something  more  to  be  done ;  and  it  is  that  which  we 
do  not  sufficiently  understand.  When  you  notice  the 
difference  in  the  form  and  structure  of  the  various 
parts  of  the  canal,  you  are  led  to  inquire  into  their 
different  offices.  To  say  nothing  of  the  small  glands 
scattered  through  these  organs,  observe  only  the  dis- 
tinct characters  of  the  small  and  large  intestines. 
The  contents  of  the  smaller,  after  the  removal  of  the 
chyle,  are  discharged  into  the  larger,  and  they  are 
not  permitted  to  return ;  for  a  valve,  placed  in  the 
colon,  prevents  it.  Having  passed  this  barrier,  the 
mass  falls  into  a  blind  sac,  the  coecum,  evidently 
designed  to  retain  it  for  a  certain  time.  Unquestion- 
ably some  change  is  wrought  in  the  mass  while  in 
this  receptacle,  and  something,  not  chyle,  must  be 
absorbed  from  it,  while  it  is  transported  through  the 
long  tract  of  the  colon.  What  the  change  is,  and 
20* 


234  ON   DISEASES   OF   THE   INTESTINES. 

what  the  material  absorbed,  has  never  been  explained, 
so  far  as  I  know.  I  do  not  speak  of  what  has  been 
guessed,  but  of  what  has  been  ascertained.  I  have 
never  heard  of  anj  shrewd  guesses  even.  Suppose 
it  proved  that  some  muriatic  or  other  acid  is  found  in 
the  coecum  ;  that  will  suggest  that  this  acid  has  some 
purpose ;  but  the  question  is,  what  ptirpose.  We 
must  attach  more  importance  to  the  operations  of  the 
large  intestine,  when  we  notice  that  they  are  not 
designed  to  carry  forward  their  contents  rapidly,  but 
the  contrary.  After  its  resting-spell  in  the  coecum, 
the  faecal  mass,  a  dead  weight,  must  be  started  up 
from  that  pouch,  be  carried  through  the  ascending, 
transverse,  and  descending  colon,  and  in  its  course 
must  meet  an  obstacle,  evidently  designed,  at  the 
angle  formed  between  these  two  last  portions  of  that 
intestine.  I  may  mention  also  some  delay  in  the 
passage  through  the  sigmoid  flexure  of  the  same 
intestine.  Where  there  are  provisions  so  evidently 
fitted  to  hold  back  the  mass  in  its  course,  we  can  see 
how  easily  obstructions  may  take  place  to  the  easy 
and  perfect  accomplishment  of  the  functions  of  this 
machinery.  In  addition  to  the  mechanical  obstacles 
to  the  rapid  passage  of  the  faeces,  we  know  that  the 
change  of  the  semi-fluid  mass  to  a  state  of  comparative 
solidity  may  be  carried  beyond   its   due  point,  and 


ON   DISEASES   QF   THE   INTESTINES.  235 

thus  a  new  difficulty  arises  in  the  process  of  defeca- 
tion. 

Some  explanation  is  thus  suggested  of  the  habitual 
constipation,  so  common  among  persons  not  leading 
natural  lives;  and  some  explanation,  also,  in  regard 
to  other  diseases  of  the  bowels.  But  there  is  a  great 
variety  in  these  diseases,  which  we  should,  no  doubt, 
better  understand,  if  their  normal  functions  were  more 
fullj  known  to  us. 

A  disorder  in  any  one  part  of  the  alimentary  canal 
may,  directly  or  indirectly,  affect  all  other  parts  of  it. 
It  is  chyme,  and  not  crude  food,  which  can  be  acted 
upon  properly  in  the  duodenum  and  other  intestines. 
If,  then,  the  food,  while  in  the  stomach,  be  not  changed 
into  chyme,  more  or  less  disorder  may  be  produced 
both  in  the  small  and  large  intestines.  In  like  man- 
ner, if  a  failure  should  occur  in  any  part  of  the  intes- 
tines, the  portion  of  the  canal  below  that  part  must 
receive  the  materials  in  a  comparatively  crude  state, 
so  that  here  also  the  disorder  would  be  propagated 
from  the  superior  to  the  inferior  part.  This,  which 
seems  so  obvious  in  theory,  is  found  true  in  fact.  But 
I  must  add  that  this  is  not  found  to  be  true  invariably. 
We  must  always  be  cautious  in  adopting  unqualified 
and  universal  principles,  especially  in  regard  to  living 
bodies.     In  a  vigorous  state  of  the  digestive  organs,  a 


236  ON  DISEASES   OF  THE   INTESTINES.  ^ 

proportion  of  the  food  may  pass  through  the  canal^ 
quite  unchanged,  without  occasioning  any  manifest 
inconvenience.  It  is  well  known  that  seeds  pass  in 
this  way  without  losing  their  vitality,  for  they  ger- 
minate afterwards. 

Again,  it  is  often  found  that  a  disease  in  any  part 
of  the  intestines,  the  colon  for -instance,  disorders  the 
stomach  and  small  intestine,  as  well  as  the  parts 
below  it.  Here  a  different  explanation  is  required; 
and  the  best  is  that  the  parts  above  the  original  dis- 
ease are  affected  by  sympathy.  I  shall  not  dispute 
with  any  one  who  carps  at  this  word,  sympathy,  so 
long  as  he  will  allow  that  the  influence  of  the  lower 
part  upon  the  upper  is  to  be  attributed  to  a  vital  power ; 
not  like  that  considered  above,  which  consists  in  the 
transmission  of  a  crude  material.  It  should  be  noted 
that  the  lower  part  may  be  influenced  through  the 
same  vital  power,  where  the  higher  part  is  diseased. 
Thus,  a  disease  of  the  stomach  may  disorder  .the  parts 
below  it  in  two  different  modes. 

I  do  not  adduce  evidence  in  support  of  the  proposi- 
tions I  have  laid  down.  A  careful  observer  cannot,  I 
think,  fail  to  discover  instances  which  prove  them. 
But  now,  do  you  ask,  whether  we  can  always,  in  dis- 
eases of  the  alimentary  canal,  satisfy  ourselves  as  to 
the  part  first  affected,  and  as  to  the  mode  of  the  prop- 


ON   DISEASES   OF  THE  INTESTINES.  237 

ftgation  in  each  individual  case  ?  To  this  question  I 
must  answer,  no.  I  have  pointed  out  the  modes  in 
which  I  believe  that  disease  in  one  part  affects  another, 
as  preparatory  to  another  statement ;  this  is,  that  in  a 
violent  attack  on  any  one  part,  others  are  affected 
almost  simultaneously,  so  as  to  throw  much  confusion 
upon  the  subject.  This  is  the  great  embarrassment  in 
the  early  stages  of  maladies  in  the  digestive  apparatus. 
There  are  two  other  causes  of  embarrassment  in  the 
same  tribe  of  diseases.  One  is,  that  an  inflammation 
of  the  mucous  membrane  of  the  canal  may  extend  from 
day  to  day,  so  as  to  be  subsiding  on  one  part  while  it 
is  increasing  upon  another,  as  erysipelas  does  on  the 
skin,  and  as  a  fire  does  upon  grass.  The  other  is, 
that  the  stomach  is  often,  as  the  intestines  are  occasion- 
ally, affected  by  sympathy  with  some  distant  organ ; 
and  the  disorder,  thus  introduced  into  one  part  of  the 
canal,  may  in  some  way  derange  other  parts  of  it. 

Here  are  the  difficulties.  I  believe  that,  when  we 
can  get  an  exact  history  of  the  disease,  and  an  account 
of  its  precursors,  a  due  consideration  of  the  whole  will 
enable  us  to  overcome  these  difficulties  in  a  good 
measure.  Not,  however,  always,  nor  entirely.  Such 
embarrassments  may  bring  to  your  mind  what  I  have 
eaid  of  our  imperfect  knowledge  of  the  normal  func- 
tions of  the  organs  concerned. 


238  ON  DISEASES   OF  THE   INTESTINES. 

The  difficulties,  thus  brought  before  jou,  relate  to 
the  question  as  to  the  primary  seat  of  trouble,  or  of 
disease,  in  disorders  of  the  alimentary  canal.  When 
this  question  is  answered,  we  have  to  inquire  what 
this  original  affection  consists  in.  To  meet  this  in- 
quiry, let  me  say  that  there  are  two  very  obvious 
modes,  in  which  a  disorder  in  this  canal  may  com- 
mence. The^r^^  is  by  an  article  introduced  into  it, 
which  is  offensive  to  it,  or  to  some  part  of  it.  Thus, 
ipecacuanha  will  occasion  vomiting,  and  sulphate  of 
magnesia  will  occasion  a  diarrhoea.  The  second  is  a 
disease  on  some  one,  or  more  spots  in  any  one  of  the 
coats,  or  tissues  of  the  canal.  Thus,  an  inflammation 
in  either  of  these  coats,  or  a  paralysis  in  the  muscular 
coat,  may  be  supposed  to  be  the  primary  affection. 
An  inflammation  of  the  mucous  coat  of  the  stomach 
may  cause  vomiting,  as  well  as  the  introduction  of 
ipecacuanha  into  that  organ.  Vomiting  occasioned 
by  ipecac,  will  usually  cease  soon  after  the  offending 
cause  is  removed;  and,  after  a  period  of  rest,  the  patient 
is  soon  well,  provided  he  "was  well  before.  When  the 
mucous  coat  of  the  stomach  is  inflamed,  the  disease 
must  go  through  a  certain  course,  during  which  the 
functions  of  the  stomach  must  be  impaired  or  arrested  ; 
and  other  symptoms  will  ensue,  more  or  less,  accord- 
ing to  the  extent,  character,  and  violence  of  the  in- 


ON  DISEASES   OF  THE   INTESTINES.  239 

fiammation.  Analogous  remarks  will  hold  true  as  to 
cases,  in  which  the  intestines,  in  any  of  their  parts,  are 
the  seat  of  the  inflammation. 

It  was  stated  that,  when  ipecac,  is  taken  into  the 
stomach,  it  excites  efforts  by  which  it  is  removed  ;  and 
other  substances,  so  received,  may  be  expelled  by  the 
intestines,  supposing  in  such  cases  that  a  sufficient 
quantity  is  taken  to  provoke  the  necessary  efforts. 
Such,  however,  are  not  the  effects  of  all  offensive 
substances ;  and,  when  they  are  not,  it  may  be  proper 
to  adopt  measures  either  to  provoke  the  salutary  evac- 
uations, or  to  neutralize  the  offending  article. 

When  it  is  ascertained  that  the  disease  is  an  inflam- 
mation, we  take  measures,  negative  or  positive,  to 
counteract  this  morbid  affection.  By  negative  meas- 
ures, in  this  case,  would  be  understood  rest  and  absti- 
nence, more  or  less  complete ;  allowing  only  bland 
articles  to  be  introduced  into  the  stomach,  and  in 
limited  quantities,  so  as  to  allow  the  disease  to  go 
through  its  ordinary  processes  with  the  least  possible 
interruption.  Treated  in  this  way,  a  diarrhoea,  the 
consequence  of  an  inflammation  in  the  mucous  coat  of 
the  intestines,  may  pass  away  with  very  little  incon- 
venience. 

But  now,  suppose  the  inflammation  to  be  severe, 
and,  perhaps,  to  extend  to  the  muscular  coat;   then 


240  ON   DISEASES   OF   THE   INTESTINES. 

motion  of  the  diseased  part  may  cause  severe  pain, 
and  the  lameness  may  be  so  great  as  to  impede  the 
passage  of  any  material  through  it.  To  get  a  distinct 
view  of  the  subject,  let  us  imagine  the  inflammation 
to  occupy  a  ring  of  the  intestine,  say  four  to  twelve 
inches  in  width.  It  is  easy  to  understand  that  this 
part  may  be  lamed,  as  the  fingers  sometimes  are,  by 
rheumatism,  so  that  they  cannot  be  opened  or  shut. 
Suppose  such  a  diseased  patch  in  the  colon,  very  much 
less  than  we  often  find  after  a  fatal  dysentery,  what 
effects  may  we  anticipate  ?  The  patient  may  be  pre- 
sumed to  have  the  usual  materials  in  the  canal,  above 
and  below  the  diseased  part.  Those  below  it  may  be 
discharged  without  material  difficulty.  Those  above 
it  would  occasion  a  great  deal  of  difficulty ;  more  or 
less,  according  to  the  extent,  character  and  violence, 
of  the  inflammation.  The  sound  portions  above  would 
continue  to  carry  down  their  contents  to  the  inflamed 
part ;  but  here  an  embarrassment  must  ensue.  This 
lame  part  could  not  expand  with  freedom,  nor  yield 
to  the  pressure  so  as  to  give  an  entrance  to  the  mate- 
rials brought  to  it.  Or  it  might  allow  only  a  small 
portion  to  enter  it  occasionally,  carrying  that  through 
it  slowly  and  with  pain.  But  this  small  portion  would 
not  pass  alone  into  the  sound  intestine  below  it.  It 
would  be  accompanied   by  some   product  from  the 


ON   DISEASES   OF   THE   INTESTINES.  24^ 

morbid  surface.  This  surface  would  pour  out  an 
extra  portion  of  mucous  or  serous  fluid,  or,  perhaps, 
some  blood,  and,  ultimately,  some  pus.  Meanwhile, 
the  pressure  of  faeces  from  above  would  be  constantly 
provoking  an  attempt  in  the  morbid  part  to  receive 
and  transmit  them.  In  such  a  case  the  actual  dis- 
charges from  the  bowels  would  consist  mainly  of  the 
fluids  from  the  inflamed  surface,  as  above  described, 
with  very  little,  if  any,  faecal  matter.  This  matter 
would  be  wrapt  up  in  the  mucous  and  morbid  products, 
and  would  rarely  pass  in  any  great  quantity  until  the 
violence  of  the  inflammation  should  subside.  If  such 
a  disease  should  be  of  large  extent  it  would  be  attended 
by  constitutional  affections,  of  which  one  symptom 
would  be  great  prostration  of  strength.  You  see  here 
we  have  a  case  of  dysentery,  vie^ved  as  if  the  parts 
affected  were  opened  to  our  inspection.  My  design 
has  been  to  give  you  what  I  consider  the  •  true 
explanation  of  this  disease,  including  such  general 
remarks  as  would  apply  to  milder  affections  of  the 
inflammatory  kind  in  the  intestinal  canal.  I  shall 
say  nothing  of  treatment.  My  purpose  is  answered 
if  I  have  suggested  the  proper  way  of  regarding  dis- 
eases of  the  alimentary  canal.  I  have  treated,  in  the 
most  elementary  way,  of  inflammation  as  disqualifying 
the  canal  for  performing  its  common  functions,  and  aa 
21 


242  ON   DISEASES   OF   THE    INTESTINES. 

occasioning  the  production  of  morbid  matters,  which 
are  discharged  from  the  body.  There  are  other 
organic  affections  of  the  same  parts,  which  may  inter- 
fere with  the  proper  motions  of  the  intestinal  canal, 
or  obstruct  the  passage  of  its  contents ;  such  as 
tumors,  whether  benign  or  malignant.  It  is  not  in 
my  plan  to  treat  of  these. 

To  understand  well  a  disease  of  the  intestines  we 
should  know  from  day  to  day  all  the  ingesta ;  every- 
thing taken  into  the  stomach,  solid  or  liquid ;  in- 
cluding the  time  when  each  portion  is  taken  and  the 
quantity.  We  should  next  see  each  dejection  from 
the  bowels  by  itself,  just  as  it  took  place,  withoijt 
any  mechanical  disturbance  of  it,  noting  the  period 
of  its  occurrence.  Last,  we  should  ascertain  how  the 
patient  has  passed  his  time,  whether  in  exercise,  or  at 
rest ;  whether  at  ease,  or  in  pain ;  whether  under 
febrile  disturbance,  or  calm  and  cool.  It  is  not  so 
easy  to  learn  all  these  details  respecting  adults,  as  it 
is  in  respect  to  young  children.  You  will  therefore 
find  a  great  advantage  in  studying  diseases  of  the 
stomach  and  bowels  in  children.  If  you  get  faithful 
reports  from  their  attendants,  you  may  often  under- 
stand, almost  exactly,  what  has  been  going  on  in  their 
digestive  organs.  It  is  true,  indeed,  that  you  see  in 
them    the    most    simple    diseases ;    but    a  familiar 


ON   DISEASES   OF   THE   INTESTINES.  243 

Acquaintance  with  these  prepares  you  for  the  study 
of  other  affections  of  the  same  parts. 

In  the  beginning  of  this  letter  I  referred  to  two 
affections  of  the  coecum  and  colon,  on  which  I  have 
something  to  offer  you.  The  first  I  shall  mention  is 
an  undue  enlargement  of  the  ascending  colon,  some- 
times, perhaps,  extended  to  the  whole  colon.  The 
ascending  colon  has  to  carry  up  the  faeces  in  opposition 
to  gravity,  when  the  body  is  in  an  erect  position.  It 
is  fitted  for  its  office,  and  performs*  it  without  attract- 
ing attention  in  persons  leading  a  natural  life.  But 
in  some  individuals  a  failure  frequently  takes  place, 
and  an  undue  quantity  of  air  accumulates  in,  and  dis- 
tends this  part  of,  the  intestine.  A  certain  portion  of 
air  excites  the  organ  to  contract,  and  thus  is  salutary. 
But,  if  it  fails,  the  muscular  power  of  the  organ  is 
impaired  by  the  distention,  and  from  year  to  year 
that  organ  becomes  less  and  less  able  to  do  its  proper 
work.  It  is  in  sedentary  people,  especially  in  those 
of  them  who  are  fat  and  sluggish,  moving  slowly 
when  they  do  move,  that  this  trouble  is  the  worst ; 
but  I  believe  that  it  exists  in  a  slight  degree  in  many 
individuals  not  like  those  above  described.  Tliose. 
who  are  affected  in  this  way,  are  habitually  costive  and 
Buffer  much  from  flatus  in  the  bowels.  They  have 
periods  when  they  are  generally  uncomfortable  and 


244  ON   DISEASES   OF   THE   INTESTINES. 

complain  particularly  of  some  uneasiness  about  the 
right  side  of  the  abdomen,  where,  if  thej  are  not  too 
fiit,  some  fulness  may  be  discovered.  As  happens 
most  frequently  in  regard  to  sensations  within  the 
great  cavities,  the  seat  of  the  uneasiness  is  not  very 
clearly  ascertained.  Some  doctor,  who  is  so  learned 
as  to  know  that  the  liver  is  on  the  right  side,  is  apt 
to  think  of  that  organ.  The  patient  is  then  adjudged 
to  be  bilious  J  and  is  under  suspicion  of  a  diseased 
liver.  He  takes  a  blue  pill  for  a  few  nights,  and 
Seidlitz  powder  in  the  mornings.  The  intestines  are 
unloaded  and  the  patient  is  relieved.  Then  it  is  con- 
sidered as  proved  that  the  dijGficulty  was  in  the  liver, 
and  that  the  blue  pill,  being  the  police  officer,  who  has 
the  special  charge  of  that  organ,  has  put  all  things  to 
rights.  I  feel  well  assured  that  something  like  this 
is  the  case  in  a  large  proportion  of  the  "  liver  cases," 
so  called.  Here  is  an  error  in  diagnosis,  it  may  bo 
said,  yet  the  patient  finds  relief  from  the  treatment, 
and  that  is  enough.  Is  it  so  ?  Does  error  often  lead 
to  truth,  or  to  a  wise  course  ?  The  patient  is  led  to 
believe  that  he  is  the  subject  of  a  disease,  or  difficulty, 
which  cannot  be  helped  without  an  active  medicine, 
frequently  repeated.  When  he  is  better,  he  is  not  told 
how  to  keep  so.  It  is  not  suggested  to  him  that  a 
cshange  in  his  habits  is  requisite.     The  disease  may 


ON  DISEASES  OF  THE  INTESTINES.  245 

be  too  great  and  of  too  long  standing  to  admit  of 
entire  relief,  but  it  may  still  be  lessened  b/  diet  and 
regimen.  When  not  so  confirmed,  much  may  be  done. 
Exercise,  and  especially  walking,  must  be  enjoined  as 
absolutely  necessary.  To  this  should  be  added  friction 
over  the  abdomen,  and  espa^ially  over  the  colon.  In 
this  way  the  difficulty  may  be  relieved,  in  part  at 
least.  It  may  be  useful  to  add  laxative  food ;  but 
how  far  this  can  be  done  with  advantage  must  be 
studied  out  in  each  case.  The  difficulty  on  this  point 
arises  from  the  flatulence,  which  is  increased  by  such 
food,  when  it  does  not  succeed  in  making  the  bowels 
sufficiently  active.  Sometimes  a  portion  of  gently 
stimulating  articles,  such  as  are  called  carminative, 
will  help  the  laxative  articles.  It  is  a  case  where 
mustard-seed  may  be  tried.  But  in  obstinate  cases, 
such  as  come  mostly  under  the  charge  of  the  physi- 
cian, some  laxative  medicine  must  be  used  frequently, 
perhaps  daily.  This  medicine  should  be  the  mildest 
which,  on  trial,  is  found  to  answer  the  purpose ;  and 
the  patient  must  be  made  to  understand  that  the 
object  is  gimply  to  bring  away  the  fseces ;  and  that 
the  medicine  operates  best,  w^hen  the  dejection  is  the 
most  natural  in  its  aspect.  By  pursuing  such  a 
course  st-eadily  there  is  some  chance  for  recovery  in 
persons  nnder  fifty ;  but  in  those  who  are  beginning 
21* 


246  ON   DISEASES   OF  THE   INTESTINES. 

to  get  old,  we  may  be  satisfied  if  we  can  prevent  an 
increase  of  the  disease.  In  persons  who  suffer  from 
this  disease  of  the  colon  an  enema  will  not  suffice,  for 
the  faeces  are  not  brought  within  its  reach.  In  bad 
cases  Seidlitz  powders.  Congress  water,  and  similar 
articles  may  not  be  sufficient  to  bring  the  loaded  and 
debilitated  organ  into  action.  A  dinner-pill,  or  a  pill 
at  bed-time,  or,  perhaps,  more  than  one,  will  be 
needed  to  effect  the  object ;  or  rhubarb  may  be  used 
for  those  on  whom  it  acts  kindly.  When  the  medi- 
cine is  not  quite  enough,  the  load  may  be  helped 
through  by  an  injection  of  cold  water.  In  this 
troublesome  disease  the  physician  must  watch  the 
patient  for  a  while,  and  teach  him  how  to  judge  of  the 
effects  of  remedies ;  for  there  are  few  who  can  learn 
their  lesson  without  a  tutor. 

I  may,  perhaps,  have  exaggerated  the  picture  of  this 
disease ;  but  something  like  it  is  frequent  among 
sedentary  persons,  especially  among  those  who  are 
full  feeders.  Of  course,  there  is  every  difference  of 
deo-ree.  The  disease  mio;ht  be  included  under  that  of 
habitual  constipation.  But  the  constipation  does  not 
necessarily  include  the  general  uneasy  state  of  the 
abdomen,  nor  the  particular  suffering,  or  discomfoi't  on 
the  right  side.  In  many  cases  of  constipation  the 
whole  trouble  ia  in,  or  near  to  the  rectum. 


ON   DISEASES   OF   THE   INTESTINES.  247 

There  is  another  disease,  in  which  the  coecum  may 
be  suspected  to  take  a  part,  which  is  not  extremely 
rare  ;  and  yet,  so  far  as  I  know,  it  has  not  been  dis- 
tinctly described.  I  will  attempt  the  description,  but 
may  not  be  successful ;  for  there  is  great  variety  in 
the  severity  and  in  all  the  circumstances  of  the  cases, 
which  I  include  under  this  head.  It  came  to  my 
knowledge  gradually,  in  a  group  with  other  diseases 
in  the  same  vicinity.  After  I  had  been  led  to  distin- 
guish it  from  the  others,  I  could  look  back  and  find 
that  I  had  seen  it  before. 

In  my  early  years  I  noticed,  as  others  have  done, 
that  in  peritonitis  the  inflammation  was  greatest'  on 
the  right  side  of  the  abdomen,  and  in  the  lowest  half 
of  it.  Let  me  call  this  lower  half  the  iliac  quarter , 
for  it  extends  somewhat  beyond  what  is  called  the 
iliac  region.  Subsequently  I  found  that  this  quarter 
was  also  the  seat  of  other  diseases,  oftener  than  the 
corresponding  part  on  the  left  side.  I  may  mention 
painful  affections  and  tumors  of  different  sorts,  which 
I  met  with  on  the  right  side  more  than  on  the  left. 
At  length,  within  the  last  fifteen  years,  perhaps,  I  got 
to  distinguish  the  particular  disease,  which  I  wish 
now  to  make  known  to  you.  I  must  give  a  name  to 
this  affection,  as  it  is  inconvenient  to  get  on  without 
one ;  therefore,  in  the  present  state  of  our  knowledge, 


248  ON   DISEASES   OF   THE   INTESTINES. 

I  will  denominate  it  a  'painful  tumor  near  the 
coecum.  I  will  state  some  cases  of  it  before  giving  a 
general  description.  There  is  something  in  common 
to  these  cases,  while  they  differ  in  their  extent,  vio- 
lence and  duration. 

A  young  lady,  when  absent  from  home  in  the 
spring  of  the  year,  took  cold,  as  she  said.  She 
became  quite  sick,  and  had  much  trouble  in  the  stom- 
ach and  bowels  for  two  or  three  weeks.  She  did  not 
get  quite  well,  and  the  same  symptoms  returned  more 
than  once  after  she  came  home.  It  became  a  question 
whether  she  had  a  partial  peritonitis,  and  at  any  rate 
there  was  suffering  in  the  right  iliac  quarter.  An 
attack  took  place  again  in  the  summer,  when  she  was 
at  some  distance  from  home.  This  was  more  obstinate 
than  the  earlier  ones,  and  confined  her  to  her  bed.  At 
this  period  the  case  was  described  to  me,  and  I  asked 
if  there  was  not  a  little  tumor  in  the  right  iliac 
quarter.  Her  physician  was  very  careful  and 
thoughtful ;  he  said  he  had  examined  the  parts  com- 
plained of,  and  he  believed  there  was  not  any  such 
tumor.  He  was  not,  however,  then  acquainted  with 
the  disease.  Soon  after  this  I  visited  the  lady  and 
detected  the  tumor.  It  did  not  lie  superficially,  so  that 
't  was  not  felt  in  passing  the  hand  over  the  abdomen ; 
out  it  was  perceived  at  once  on  pressing  the  fingers 


ON   DISEASES   OF   THE   INTESTINES.  249 

down  to  some  little  depth.  It  was  at  the  point  where 
a  horizontal  line,  drawn  from  the  anterior  superior 
spinous  process  of  one  ilium  to  that  of  the  other, 
crosses  the  outer  edge  of  the  right  rectus  muscle.  It 
was  in  shape  rather  oval  than  round,  and  flattened  j 
and  was  larger  than  an  almond,  somewhat  movable, 
and  so  tender  to  the  touch  that  the  patient  wanced,  or 
cried  out,  every  time  that  I  pressed  on  it.  The  pres- 
sure did  not,  however,  cause  extreme  pain.  I  found 
it  at  once,  because  I  had  before  learned  where  and 
how  to  feel  for  it ;  otherwise  I  might  have  missed  it. 
The  patient  had  now  been  sick  for  two  or  three  weeks^ 
her  symptoms  varying  much  in  severity.  The  prin- 
cipal complaint  was  a  pain  in  the  right  side  of  the 
abdomen,  and  more  in  the  lower  than  the  upper  part 
of  that  side.  With  this  her  appetite  was  quite  lost  at 
times,  but  not  constantly.  She  had  frequent  attacks 
of  the  pain,  with  some  febrile  symptoms.  They  were 
attributed  to  the  food  she  took,  to  the  exertions  she 
made  when  feeling  better,  and  to  a  deficiency  in  the 
alvine  discharges.  Laxatives  afforded  her  great  relief 
for  a  time,  but  a  frequent  repetition  of  them  was 
necessary.  She  remained  in  a  tender  state  for  several 
weeks,  so  as  to  delay  her  return  home,  and  it  was 
necessary  to  remove  her  with  peculiar  care.  At  home 
sdie  soon  recovered  strength  enough  to  move  about, 


250  ON  DISEASES   OF   THE   INTESTINES. 

but  for  many  months  she  had  an  occasional  attack  of 
the  disease.  As  this  -was  now  understood,  it  was 
arrested  very  soon  by  evacuations  of  the  bowels,  a  few 
leeches,  and,  perhaps,  a  small  blister,  with  bodilj  rest 
and  abstinence.  Within  a  year  from  her  first  attack 
she  became  quite  well,  and  eight  or  ten  years  have 
how  passed  without  any  return  of  the  malady. 

I  have  seen  cases  more  severe  than  this,  and  some 
much  more  mild  and  shorter.  Of  the  last  description 
is  the  following. 

In  1849,  H.  M.,  a  woman  between  thirty  and  forty, 
of  very  good  habits,  and  leading  an  easy  life,  though 
a  domestic,  complained  to  me  of  pain  on  the  right  side 
of  the  abdomen.  She  had  had  it  for  two  or  three 
weeks,  and  felt  less  able  to  attend  to  her  business  than 
usual,  yet  had  not  relinquished  it  entirely ;  she  could 
not  assign  any  cause  for  the  pain.  On  examination  I 
found  a  tumor  much  like  that  in  the  preceding  case,  and 
in  the  same  situation.  It  was  not  discovered  on  light 
pressure,  but  on  pressing  the  fingers  somewhat  into  the 
abdomen  while  the  patient  was  on  her  back.  She  was 
not  aware  that  there  was  any  tumor,  or  that  any  was 
suspected,  but  she  complained  at  the  moment  Avhen  I 
touched  it,  and  did  not  acknowledge  any  like  tender- 
ness upon  pressure  in  any  other  part  of  the  abdomen. 
The  pain,  however,  exten'ded  beyond  its  seat,  particu- 


ON   DISEASES   OF   THE   INTESTINES.  251 

larly  above  it.  She  had  one  symptom,  which  I  have 
never  known  in  any  other  case.  This  was  pain  in  the 
iliac  quarter  on  sitting  down  and  on  rising  from  her 
chair.  It  was  not  a  severe  pain.  There  was  not  any 
strongly-marked  constitutional  affection,  though  she 
felt  less  well  than  usual. 

The  remedies  employed  were  cathartics,  leeches 
twice  and  blisters  twice,  over  the  seat  of  the  tumor. 
Under  the  use  of  these  she  grew  better,  but  at  the  end 
of  a  fortnight  the  tumor  could  still  be  felt.  I  then 
ordered  an  ointment  of  iodine  and  hydriodate  of  potass 
to  be  applied  over  it,  and  under  the  use  of  this  she 
got  quite  well  within  two  or  three  weeks.  Whether 
the  ointment  helped  it  is  uncertain;  but,  in  respect 
to  the  benefit  of  the  other  remedies,  I  felt  no  doubt,  as 
manifest  relief  followed  each  one  of  them.  In  this  case 
the  tumor  could  be  covered  entirely  by  a  half-dollar. 
She  has  not  had  any  return  of  the  disease. 

It  was  I  believe  at  an  earlier  date  that  I  saw  Mr. 

B ,  a  young  gentleman,  in  consultation,  who  had 

acute  pain  in  the  abdomen,  somewhat  of  the  character 
of  colic  pain.  It  was  severe,  and  he  was  on  his  bed. 
I  saw  him,  I  think,  on  the  second  day  of  the  attack, 
and  was  told  that  he  had  had  a  similar  affection  not 
many  weeks  previous.  On  examination  I  found  dis- 
tinct tenderness  at  the  spot  before  described,  but  there 


252     ON  DISEASES  OF  THE  INTESTINES. 

was  very  little,  if  any,  tumor.  By  remedies  like 
those  used  in  the  last  case  he  was  soon  relieved  entire- 
ly. I  inquired  from  time  to  time  afterwards,  and 
found  that  he  had  not  had  a  third  attack.  Though 
the  evidence  of  a  tumor  was  very  equivocal,  and  at 
the  most  it  was  very  small,  I  have  always  suspected 
that  the  disease  was  the  same  as  in  the  preceding  cases, 
and  that  its  recurrence  was  probably  prevented  by  the 
remedies.  If  so,  he  gained  by  the  severity  of  the 
case,  which  obliged  him  to  seek  medical  aid  at  once. 

The  following  is  a  case  of  much  greater  severity 
and  duration,  which,  however,  I  consider  as  similar  to 
the  others  in  its  essential  character.     The  patient, 

Mr.  E, ,  was  past  middle  life,  a  business  man,  of 

active  habits,  and  of  a  distinctly  nervous  temperament. 
He  had  been  sick,  much  of  the  time  in  bed,  for  two  or 
three  months  before  I  was  called  to  him  in  consulta- 
tion. He  had  a  good  physician,  who  was  not,  however, 
acquainted  with  the  disease.  This  man  had  a  large 
tumor,  two  inches  in  diameter,  which  came  under  the 
spot  before  described  on  the  borders  of  the  iliac 
quarter.  I  do  not  mean  that  the  angle  of  the  lines 
described  was  over  the  centre  of  the  swelling.  The 
tumor  laid  nearer  the  surface  than  either  of  the  others, 
and  felt  as  if  extending  deeper.  In  other  words,  it 
was  thicker  than   the  others.     It  was  painful  and 


ON  DISEASES   OF   THE   INTESTINES.       ,    258 

tender  to  the  touch.  There  were  febrile  symptoms, 
which  had  been  varying  from  time  to  time.  The 
digestive  apparatus  was  all  wrong.  He  was  so  sick 
that  his  life  was  considered  in  danger.  Leeches  and 
vesication  had  decidedly  good  effects  as  regarded  pain 
and  soreness,  and  the  size  of  the  tumor  was  lessened 
somewhat  under  the  use  of  them.  Strong  cathartics, 
acting  freely,  afforded  him  great  relief,  so  that  he 
never  felt  as  if  he  had  enough.  The  quantity  of  faeces 
was  very  large,  more  than  his  food  seemed  to  account 
for.  The  evacuations  never  caused  any  marked  change 
in  the  swelling,  as  if  an  accumulation  in  the  intestine 
had  taken  place.  For  a  while  he  gained  in  strength 
and  spirits,  took  food  well,  and  the  tumor  became 
smaller.  But  when  he  had  been  sick  five  or  six 
months  a  new  trouble  came  on.  This  was  insanity. 
This  occasioned  his  removal  from  town,  and  I  saw  no 
more  of  him.  This  occurred  ten  or  more  years  ago, 
and  I  believe  he  is  still  living  with  his  mind  deranged. 
So  far  as  I  have  been  able  to  learn,  the  first  disease 
has  never  been  troublesome  since  he  left  town,  and 
probably  it  has  subsided.  The  termination  of  this 
case  was  the  worst  I  have  ever  known.  There  was 
not,  however,  anything  to  show  that  the  two  diseases 
were  connected,  except  that  one  followed  the  other. 
I  will  give  you  one  more  case,  and  a  very  interest- 
22 


254  .        ON   DISEASES   OF   THE   INTESTINES. 

ing  one.     It  is  that  of  a  young  physician,  Dr.  H ^ 

who  had  been  engaged  in  unwonted  labor  three  or 
four  months  before  his  sickness.  It  occurred  in  the 
summer  of  1846.  When  I  first  saw  him  he  was  on 
his  bed,  prostrated,  with  a  very  bad  and  anxious 
countenance,  modified  in  expression  by  opium,  which 
he  had  been  taking  freely ;  skin  hot,  pulse  hard  and 
frequent.  His  abdomen  was  very  hard,  painful  and 
tender.  His  worst  pain  was  in  the  right  iliac  quar- 
ter^ and  I  found  there  a  tumor  in  the  usual  place,  of 
which  he  was  not  aware.  This  was  very  tender  to 
the  touch  ;  a  silver  dollar  would  about  cover  it.  His 
own  recollection,  of  the  preceding  part  of  the  disease 
particularly,  has  been  recently  given  to  me  in  the  fol- 
lowing words : 

"  The  disease  commenced,  I  think,  about  twelve 
days  before  you  saw  me.  At  that  time,  while  driving 
out  of  town  in  the  evening,  and  through  some  low 
ground,  after  leaving  a  very  hot  room,  I  became  much 
chilled.  It  was  not  merely  a  sensation  of  coldness, 
but  a  distinct  rigor,  the  effect  lasting  several  hours. 
This  was  followed  in  a  day  or  two  by  tenderness  of 
the  abdomen,  and  a  general  sensation  of  being  ill. 
The  tenderness  increased  continually,  so  that,  for  sev- 
eral days  before  I  saw  you,  the  motion  of  the  vehicle 
over  the  pavement  caused  me  great  pain.     On  Satur- 


ON   DISEASES   OF  THE   INTESTINES.  255 

day  the  pain  and  tenderness  were  constant,  and  it 
seemed  as  if  I  could  count  every  stone  I  rode  over. 
At  night  I  went  to  mj  bed  and  took  laudanum  very 
freely.  The  agony  was  such  I  could  not  remain  in 
bed,  and  much  of  the  night  I  was  walking  about  the 
room.  I  continued  the  laudanum  through  the  night, 
but  do  not  think  much  of  it  was  retained ;  at  all  events 
it  did  not  produce  sleep,  nor  at  all  mitigate  the  pain. 
On  Sunday  morning  I  went  out  as  usual,  but  the 
motion  was  so  painful  I  could  not  allow  the  horse  to 
go  beyond  a  walk.  After  seeing  a  few  patients  I  felt 
that  I  could  do  no  more.  I  then  got  some  leeches  and 
went  home  to  apply  them,  but  finding  that  I  was 
growing  worse,  sent  for  you  soon  afterwards.  At 
this  time  my  abdomen  was  very  hard  all  over,  my 
face,  as  I  saw  in  the  glass,  of  a  dark  purplish  color, 
my  breathing  very  short,  labored  and  painful ;  in  fact, 
I  thought  I  was  dying.  You  immediately  opened  a 
vein.  The  blood  at  first  was  very  thick ;  it  looked  to 
me  like 'tar,  but  it  soon  came  to  move  freely  and  ran 
a  good  stream ;  this  you  allowed  it  to  do  till  I  was 
faint.  The  relief,  as  to  the  pain  and  dyspnoea,  was 
decided  and  immediate.  You  then  directed  twenty 
leeches  to  be  applied  to  the  abdomen  (I  had  previously 
applied  a  few),  and  in  the  evening  you  and  Dr.  Bige- 
low  advised  a  repetition  of  the  bleeding,  and  I  believe 


256  ON   DISEASES   OF   THE   INTESTINES. 

about  as  much  blood  was  taken  as  in  the  morning. 
No  blister  was  applied  over  the  abdomen  then ;  but, 
some  time  after,  you  directed  a  succession  of  them  to 
be  applied  over  the  hard  bunch,  which  appeared  in 
the  right  iliac  region,  to  promote  absorption.  This 
bunch  disappeared  quite  slowly,  and  it  was  a  number 
of  weeks  before  the  tenderness,  which  followed  it,  was 
gone.  During  my  convalescence  I  had  repeated 
attacks  of  pain,  resembling  colic,  but  have  never  had 
any  since,  nor  has  there  ever  seemed  to  be  any  obstruc- 
tion or  dijfficulty  in  the  bowels  since  that  time,  although 
it  took  me  more  than  a  year  to  recover  my  strength. 
Previous  to  your  seeing  me  the  action  of  the  bowels 
was  regular." 

This  case  differs  from  all  others  I  have  seen  in  its 
violent  acute  symptoms  ;  it  caused  me  to  fear  general 
peritonitis  and  a  fatal  result.  The  relief  following  the 
bleeding  and  subsequent  purging,  removed  my  fears. 
But.  though  its  violence  was  overcome,  the  disease 
continued  for  a  long  time.     Colics  -occurred,  as  Dr. 

H has  stated ;  and  the  tumor  remained  always 

somewhat  tender,  and  at  times  painful.  The  suiFering 
was  increased  by  food,  if  taken  in  more  than  the  most 
moderate  quantity,  even  when  the  appetite  was  suffi- 
cient and  the  whole  disease  nmch  abated.  Fruit  and 
acescent  articles  were  especially  hurtful  to  him.     His 


ON  DISEASES   OF  THE  INTESTINES.  257 

feelings  led  him  to  a  constant  desire  for  full  purga- 
tives. As  in  other  cases  of  the  kind,  the  relief  from 
them  was  decided,  though  not  of  long  duration  ;  and 
the  discharges  were  always  more  copious  than  could 
have  been  expected,  from  the  quantity  of  food  taken. 
I  do  not  remember  any  disease  in  which  I  have  noticed 
this  peculiarity  so  strongly  marked,  except  organic 
affections  of  the  liver. 

Since  this  letter  was  written  a  friend  has  very  kind- 
ly handed  me  two  cases,  which  he  observed  during  the 
last  year,  and  which  appear  to  be  of  the  same  descrip- 
tion as  the  foregoing.  The  language  in  which  he 
describes  the  cases  differs  from  mine,  as  any  two  men 
may  differ  in  relating  the  same  thing.  I  had  had  a 
conversation  with  him  on  the  subject,  and  that  led  him 
to  take  special  note  of  these  cases. 

Two  cases  observed  by  Francis  Minot,  M.  D. 

''Pain  in  the  abdomen,  with  active  febrile  disturbance. 
Relief  after  leeches  and  purgatives.  Tumor  in  the 
ilio-coecal  region,  remaining  after  convalescence. 

"  A  little  girl,  aged  eleven  years,  who  had  generally 
enjoyed  good  health,  became  ill  on  Sunday,  October  the 
eighth,  1854,  without  known  cause.  She  felt  chilly, 
lost  her  appetite,  and  was  inclined  to  lie  on  the  sofa 
all  day.  She  went  to  school  the  two  following  days, 
22* 


258  ON   DISEASES   OE   THE   INTESTINES. 

though  not  feeling  well.  On  the  tenth  she  had  great 
pain  in  the  abdomen,  accompanied  bj  vomiting,  and 
followed  by  an  evacuation  of  the  bowels,  the  first  since 
the  seventh,  though  they  had  previously  been  perfect- 
ly regular. 

"  I  found  her  on  the  tenth  in  bed.  The  face  was 
flushed,  pulse  one  hundred  and  ten,  tongue  slightly 
coated.  She  complained  of  severe  pain  in  the  abdo- 
men, referred  to  the  right  side,  and  occurring  in  par- 
oxysms about  once  an  hour,  leaving  her  comparatively 
free  in  the  intervals.  She  could  lie  only  on  her 
back;  the  least  motion,  and  even  drawing  a  long 
breath,  also  causing  pain.  The  abdomen  was  moder- 
ately full  and  resonant.  On  the  right  side  it  was 
very  sensitive  to  pressure,  the  tenderness  being  exces- 
sive in  the  iliac  region.  A  cathartic  of  calomel  and 
jalap  was  ordered.  Before  it  operated  the  patient  had 
a  sharp  rigor,  followed  by  heat  and  perspiration. 
After  the  enema  she  had  a  large  solid  dejection.  She 
derived  great  comfort  from  a  fomentation  of  spongio- 
piline,  and  got  some  sleep  after  taking  opiates. 

"  On  the  twelfth  her  general  condition  was  about 
the  same.  She  lay  with  her  legs  drawn  up,  and  sup- 
ported by  pillows,  the  slightest  motion  causing  pain. 
The  face  was  pale  and  expressive  of  much  suffering, 
but  not  anxious.    Skin  of  natural  temperature ;  tongue 


ON    DISEASES   OF   THE   INTESTINES.  259 

covered  with  a  thin,  brownish,  pasty  coat ;  breath 
foul ;  pulse  one  hundred  and  twelve,  rather  hard ; 
respiration  twenty,  easy  ;  thirst,  headache.  The  ab- 
domen was  extremely  tender  throughout  the  right 
side,  but  mostly  so  in  front  of  the  anterior  superior 
spine  of  the  ilium.  Considerable  fulness  above  and 
in  front  of  the  same  point  was  evident  to  the  eye. 
Four  leeches  were  applied  to  the  seat  of  pain,  imme- 
diately after  which  there  was  great  relief  to  the  pain. 
In  the  evening  she  was  able  to  move  her  limbs  a 
little. 

''  On  the  thirteenth  I  found  a  smooth  round  tumor, 
feeling  like  an  egg,  just  in  front  of  the  spine  of  the 
ilium.  On  account  of  its  tenderness,  it  could  not  be 
freely  examined.  In  the  course  of  the  day  she  had  a 
very  copious  spontaneous  dejection,  the  first  part  of 
which  consisted  of  hard,  dry  lumps,  the  remainder 
being  soft.  She  also  passed  much  wind.  After  this, 
the  general  condition  was  much  improved.  The  pulse 
fell  from  one  hundred  and  six  to  ninety.  The  tender- 
ness, except  over  the  tumor,  was  greatly  diminished. 

"  The  next  day  I  was  able  to  examine  the  tumor  with 
more  ^  exactness,  and  made  the  following  record : 
'  Its  centre  appears  to  be  two  inches  from  the  ilium, 
on  the  right  side,  on  a  line  drawn  through  the  two 
superior  spinous  processes.    It  is  globular,  and  smooth. 


260  ON  DISEASES   OF  THE  INTESTINES. 

Its  limits  cannot  be  exactly  felt,  as  the  examination 
gives  considerable  pain.'  The  patient  had  two  abun- 
dant dejections,  after  medicine,  in  the  course  of  the 
daj,  and  was  altogether  better  in  the  evening. 

''Her  improvement  was  uninterrupted,  though  slow. 
She  could  not  dispense  with  the  pillow  under  the 
right  thigh  before  the  sixteenth,  nor  could  she  lie  on 
the  right  side,  though  she  was  able  to  sit  up  in  bed. 
On  the  fifteenth  the  tumor  is  noted  as  being  '  about 
two  inches  long  by  one  broad.' 

"  On  the  twentieth  I  recorded  as  follows  :  —  '  She 
has  been  well  since  the  last  visit  (seventeenth),  and 
has  not  been  confined  to  the  house.  The  tumor  is  felt 
deep  beneath  the  surface,  in  the  right  iliac  region.  It 
is  hard  and  round,  feeling  like  a  horse-chestnut,  and 
of  about  the  same  size,  almost  entirely  free  from  ten- 
derness.' She  recovered  perfectly,  but  I  cannot  say 
whether  the  tumor  ultimately  disappeared." 

"  Pain  and  tenderness,  with  a  deep-seated  tumor  in 
the  ilio-coecal  region,  with  slight  febrile  symptoms. 
Convalescence  in  four  days. 

''  A  married  woman,  aged  about  forty,  was  confined 
for  the  eighth  time  on  the  21st  July,  1854.  Nothing 
unusual  occurred  during  the  labor  or  convalescence. 
During  the  night  of  the  third  and  fourth  September  she 


ON  DISEASES  OF  THE   INTESTINES.  261 

was  attacked  with  severe  pain  in  the  abdomen,  which 
was  increased  when  she  lay  on  the  left  side.  No 
cause  could  be  ascribed  for  this  attack,  unless  too 
much  exertion  in  lifting  her  children. 

"  On  the  morning  of  the  fourth  she  was  in  bed,  pulse 
ninety-six ;  tongue  nearly  clean ;  skin  of  natural 
temperature ;  no  headache,  nor  pain  in  the  back  or 
limbs  ;  no  chill ;  had  had  no  dejection  for  three  days, 
except  a  slight  one  yesterday.  Decubitus  dorsal. 
Every  movement  of  the  body  was  painful,  and  she 
could  not  lie  on  the  right  side.  Abdomen  moderately 
tympanitic,  everywhere  soft,  not  tender,  except  in 
the  neighborhood  of  the  spine  of  the  ilium,  on  the 
right  side,  where  it  was  extremely  tender  for  a  space 
four  inches  square.  A  smooth  globular  tumor  was 
felt  in  the  same  place.  It  was  a  few  inches  in  diame- 
ter, lay  very  deep  beneath  the  surface,  and  was  very 
sensitive  to  the  touch.  In  the  course  of  the  day  the 
pulse  rose  to  one  hundred  and  twenty.  (Six  leeches 
to  seat  of  pain.     Castor  oil,  followed  by  enema.) 

"September  5th.  —  The  patient  experienced  great 
relief  after  the  application  of  the  leeches.  She  had 
four  dejections.  Is  now  free  from  pain,  and  feels 
much  better.  Pulse  eighty-eight,  tongue  moist,  some 
appetite,  no  thirst.     The  tenderness  of  the  abdomen 


262  ON  DISEASES   OF  THE  INTESTINES. 

has  much  diminished,  but  the  tumor  is  with  difficulty 
felt,  on  account  of  its  depth. 

"  September  7th.  — Feels  quite  well,  and  free  from 
pain.  Is  still  in  bed.  Bowels  free.  Tumor  cannot 
be  distinctly  felt. 

"  September  8th.  —  Sitting  up.  Free  from  pain 
and  tenderness." 

The  cases,  which  I  have  related,  differ  from  each 
other  in  their  severity  and  duration,  and  in  many 
important  details.  If  I  could  recall  all  I  have  seen 
this  would  be  more  fully  exemplified.  I  have  not 
seen  one  case  of  the  disease  which  has  proved  fatal ; 
so  that  no  examination  post  mortem  has  enlightened 
me  upon  its  seat  and  particular  chai-acteristics. 

What,  now,  are  the  symptoms  common  to  these 
cases  and  which  may  be  regarded  as  essential  to 
this  disease  ?  They  are  pain  in  the  right  iliac 
quarter,  but  not  confined  to  this,  for  it  often  passes 
beyond  the  limits  of  this  quarter,  particularly  upward ; 
and  a  tumor,  varying  in  size,  so  deep-seated  in  the 
abdomen  as  not  to  be  felt  without  some  direct  pressure 
on  the  part,  more  or  less  tender,  sometimes  very 
tender.  This  tumor  is  to  be  felt  near  the  outer  edge 
of  the  right  rectus  muscle  of  the  abdomen,  where  this 
IS  crossed  by  a  line  drawn   horizontally  from  the 


ON   DISEASES  OF  THE  INTESTINES.  263 

anterior  superior  spinous  process  of  the  right  ilium. 
It-  must  not  be  understood  that  the  centre  of  the 
tumor  is  to  be  found  exactly  under  the  angle  formed 
by  the  lines  above  mentioned,  only  that  some  part  of 
the  tumor  lies  under  it.  This  may  not  be  mathemat- 
ically correct :  but  I  believe  that  the  indurated  body 
will  always  be  found,  when  the  fingers  are  pressed 
down  as  near  to  this  angle,  as  one  Would  come  in  an 
examination  of  this  sort.  Constitutional  affections 
attend  this  disease  in  some  stage  of  it,  but  they  vary 
much  in  severity ;  and  so  also  does  its  duration  vary. 
I  may  add,  as  a  characteristic  of  this  painful  tumor  near 
the  coecum,  that  purgatives  give  so  much  relief  that 
the  patient  is  always  anxious  to  have  them.  Perhaps 
it  may  be  true  of  all  diseases,  in  which  the  coecum 
and  colon  are  concerned,  that  the  patient  has  a  strong 
desire  for  something  to  relieve  those  intestines  from 
the  faecal  matter  detained  in  them. 

I  have  mentioned  the  coecum  as  an  organ  affected 
in  this  disease,  but  I  have  not  shown  that  this  is  true. 
We  must  now  consider  what  is  the  organ  affected ; 
in  which  of  its  coats,  or  tissues,  the  affection  is  seated ; 
and  what  is  the  nature  of  the  affection.  I  cannot 
answer  these  questions  with  an  assurance  of  being 
right.  I  have  supposed  that  the  coecum  was  the 
organ  affected,  that  the  disease  was  seated  on  or  in  its 


264  ON   DISEASES   OF   THE  INTESTINES. 

serous  coat,  and  that  this  disease  was  an  inflammation. 
There  are,  however,  great  objections  to  this  supposi- 
tion ;  it  is  upheld  mostly  on  the  ground  that  there  are 
greater  objections  to  any  other.  In  talking  with  my 
medical  friends,  none  more  satisfactory  has  been 
suggested  to  me.  If  there  were  absorbent  glands, 
lacteal  or  lymphatic,  in  the  situation  of  the  disease, 
the  explanation  would  be  easy. 

I  think  it  will  be  readily  admitted  that,  in  the  cases 
I  have  related,  the  tumor  is  formed  by  the  process  of 
inflammation.  The  part  is  painful  and  tender ;  often 
very  tender.  Unless  in  the  case  of  Mr.  B.,  I  have 
never  seen  the  disease  at  its  very  beginning ;  and  if 
that  was  the  same  as  the  others,  it  subsided  so  soon 
as  not  to  enlighten  us  upon  its  nature.  In  all  the 
others  the  tumor  has  enlarged  and  diminished  gradu- 
ally, as  might  happen  to  a  phlegmon  not  passing  on  to 
suppuration.  It  does  not,  however,  come  within  our 
notions  of  a  phlegmon,  if,  as  I  believe,  it  never  termi- 
nates in  suppuration.  The  tumor  has  never  subsided 
suddenly,  so  as  to  justify  a  suspicion  that  it  has  dis- 
charged pus  into  the  intestines,  or  elsewhere.  Nor 
have  I  ever  found  it  to  subside,  or  to  be  diminished 
suddenly,  after  a  purgative,  as  might  happen  if  a 
faecal  mass  had  been  confined  in  the  coecum.  -  Indeed, 
the  feeling  of  the  tumor  does  not  resemble  that  of  an 


ON   DISEASES   OF   THE   INTESTINES.  265 

accumulation  of  faeces ,  such  as  I  have  sometimes  met 
with.  It  accords  better,  though  not  exactly,  with  an 
enlarged  lymphatic  gland.  It  might  be  supposed  that  it 
occupies,  or  extends  through,  all  the  coats  of  the 
coecum.  But  then  it  would  be  such  an  obstacle  to 
any  contraction  of  that  organ,  as  to  cause  great  pain 
at  the  time  ;  so  that  the  patient  would  get  to  have  a 
dread  of  cathartics,  even  though  they  might  be  fol- 
lowed by  relief  But,  as  I  have  said,  the  patient  is 
always,  or  very  often,  anxious  for  cathartics. 

Can  there  be  a  suppurative  process  on  the  mucous 
membrane  of  the  coecum,  and  is  the  tumor,  in  any 
way,  a  secondary  affection  ?  I  have  seen  such  a  dis- 
ease of  the  coecum,  and  had  no  hesitation  in  deciding 
what  it  was.  The  case  proved  fatal,  and  fully  con- 
firmed my  diagnosis.  The  symptoms  were  very 
different  from  those  I  have  stated  as  belonging  to 
this  jjaififul  tumor. 

MM.  Dupuytren  and  Grisolles,  of  Paris,  and,  I 
believe,  some  other  French  writers,  have  given  an 
account  of  phlegmon  and  abscess  in  the  iliac  fossoe. 
A  slight  knowledge  of  these  diseases,  especially  the 
name  employed  by  Grisolles  (Tumours  phlegmoneuses 
des  fosses  iliaques),  might  lead  ono  to  suppose  the 
affections  to  be  the  same;  but  it  is  not  so.  I  am 
acquainted  with  those  phlegmons,  most  common  in 
23 


266  ON   DISEASES   OF   THE   INTESTINES. 

the  puerperal  state,  but  seen  in  other  states.  I  have 
been  consulted  about  one,  in  a  man,  since  I  have  been 
engaged  in  writing  these  letters.  These  phlegmons 
almost  always  suppurate,  as  is  particularly  shown  by 
M.  Grisolles,  and  as  my  limited  experience  confirms. 
I  first  became  acquainted  with  this  disease  in  examin- 
ing a  woman  post  mortem  at  our  almshouse,  more 
than  fifty  years  ago.  That  case  was  so  remarkable  in 
one  point,  that  I  will  diverge  from  my  path  to  put  it 
on  record.  The  abscess  contained  more  than  a  gill 
of  pus.  There  was  involved  in  it,  lying  in  this  bed 
of  pus,  a  portion  of  the  external  iliac  vein.  Where 
this  vein  passed  through  the  parietes  of  the  abscess, 
at  both  its  upper  and  lower  part,  the  vessel  was  clogged 
up  by  coagulated  lymph,  showing  that  the  adhe- 
sive inflammation  (in  Mr.  Hunter's  language)  had 
taken  place  within  the  vein,  as  it  had  in  the  surrounding 
cellular  membrane.  But,  further,  between  these  two 
portions  of  lymph  suppuration  had  taken  place  within 
the  vein.  The  pus  in  the  vein  was  somewhat  colored 
by  blood,  but  not  so  much  as  to  leave  any  doubt  as  to 
its  character.  The  case  had  been  a  slow  one  probably. 
The  subject  of  it  was  an  abandoned  woman,  who  had 
been  brought  to  the  house  in  an  exhausted  state. 
You  observe  that  the  peculiarity  of  the  case  was  that 
the  vein  was  insulated  in  the  cavity  of  the  abscess, 


ON   DISEASES    OF   THE   INTESTINES.  267 

and  had  gone  through  the  same  processes  as  the 
surrounding  parts,  without  having  had  any  opening, 
by  which  it  had  communicated  with  them.  On  a 
young  admirer  of  John  Hunter,  as  I  was,  this  case, 
illustrating  his  description  of  the  different  processes 
of  inflammation  so  distinctly,  made  an  impression, 
which  has  not  been  efikced  by  time.  I  am  sure  that 
the  essential  circumstances  are  correctly  stated,  though 
I  have  done  it  from  memory.  I  believe  I  have  a 
a  record  of  them,  but  cannot  now  put  my  hands  on 
it. 

I  have  stated  more  than  once  that  suppuration  has 
not  occurred  in  any  case  of  this  painful  tumor  near 
the  coecum.  On  saying  this  lately  to  an  ingenious 
and  learned  friend,  to  whom  I  had  been  speaking  of 
this  disease,  he  asked  the  following  question  :  ''  May 
not  your  disease  have  been  tuphlo-enteritis ;  and  may 
it  not  be  that  in  the  cases,  which  did  not  terminate 
fatally,  the  nature  of  the  affection  was  not  discovered  ?  " 
This  is  a  fair  question,  and  I  leave  it  to  others  •  to 
answer  it  from  observation,  if  an  opportunity  occurs. 
I  replied  to  him  that  since  the  first  case  I  saw  of 
tuphlo-enteritis,  I  have  not  seen  one,  which  has  been 
proved  to  be  so,  that  I  did  not  recognize  at  once; 
that  this  disease  occurs  mostly  in  children,  though  not 
in  them  solely ;  that  its  symptoms  are  usually,  within 


268  ON   DISEASES    OE   THE   INTESTINES. 

the  first  few  days,  much  more  violent  than  those  in 
my  cases  at  so  early  a  period ;  that  vomiting  is,  I 
believe,  among  the  early  and  obstinate  symptoms  in 
tnphlo-enteritis,  while  in  my  cases  it  is  much  less 
remarkable,  though  it  occurred  in  some  of  them.  To 
this  I  should  add  that  the  little  tumor  felt  in  tuphlo- 
enteritis  is,  I  think,  to  be  found  somewhat  lower,  and 
not  so  near  to  the  median  line  as  the  tumor  I  have 
described.  I  submit  all  this  for  consideration  ;  with 
the  hope  that  others  will  be  able  to  explain  the  disease, 
I  have  thus  brought  to  notice,  more  perfectly  than  I 
can  do. 

In  describing  cases  of  the  disease  under  considera- 
tion I  have  stated  the  remedies  employed  more  or  less 
fully.  I  will  bring  them  into  one  view,  premising 
that  they  must  be  used  with  greater  or  less  freedom, 
according  to  the  violence  of  the  disease.  The  indica- 
tion is  to  bring  about  resolution  in  the  inflamed 
part.  It  is  very  probable  that  the  final  result  would 
be  the  same  without  medical  aid,  but  there  are  two 
reasons  for  adopting  active  treatment.  First,  there 
is  usually  so  much  pain  and  distress  when  the  physi- 
cian is  called,  that  present  relief  is  a  great  object. 
This  relief  treatment  will  afford.  Second,  in  the 
instances  which  I  have  seen,  the  disease  has  proved 
more  severe  and  more  lasting,  the  longer  it  has  con- 


ON  DISEASES  OF  THE  INTESTINES.  269 

tinued  before  the  appropriate  treatment  has  been 
adopted.  This  is  an  approximation  to  the  truth,  if  not 
a  perfectly  correct  statement. 

When  colic,  or  great  pain  in  the  bowels,  exists  at 
the  commencement  of  the  treatment,  opium  should  be 
given,  in  some  form,  until  it  gives  ease.  If,  indeed, 
there  be  a  hot  skin,  a.  frequent  and  hard  pulse,  and 
the  patient  be  sufficiently  vigorous,  venesection  should 
be  the  first  remedy.  In  the  case  of  Dr.  H.  the  benefit 
of  free  bleeding  was  unquestionable.  The  depletion 
will  probably,  in  all  cases,  diminish  the  pain  and  dis- 
tress ;  and,  after  it,  opium  will  act  more  kindly  than 
before.  Leeches  should  be  applied  where  venesection 
is  not  admissible,  or  not  required ;  in  number  from 
six  to  twenty,  according  to  circumstances.  If  there 
be  much  pain  the  opiate  should  be  used  first.  After 
the  bleeding  a  purgative  should  be  given.  After 
bleeding  the  purgative  will  probably  act  more  readily 
and  more  easily,  as  the  loss  of  blood  will,  if  I  may  so 
express  it,  liberate  the  intestine.  On  the  following 
day  a  blister  should  be  drawn  over  the  seat  of  the 
tumor.  This  and  the  other  remedies  must,  of  course, 
be  repeated,  or  not,  according  to  circumstances. 

Through  the  whole  treatment  rest  should  be  en- 
joined, and  the  diet  should  be  very  moderate  and 
%imple,  until  the  disease  is  evidently  much  lessened. 
23* 


270     ON  DISEASES  OF  THE  INTESTINES. 

If  the  treatment  is  not  begun  early,  exacerbations  are 
verj  apt  to  occur.  They  must  be  guarded  against  as 
far  as  possible ;  and,  if  they  take  place,  active  measures 
should  be  adopted  at  once.  In  an  old  or  severe  case 
the  tumor  will  remain  for  a  time  with  some  tenderness, 
after  recovery  has  taken  place  in  all  other  respects. 
In  this  state  I  think  the  external  use  of  iodine  may 
be  useful.  At  least  the  tumor  has  gone  off  under  this 
remedy  sooner  than  I  had  anticipated,  and  the  patient's 
mind  has  been  kept  easy,  and  no  injury  has  ensued 


LETTER  XIV. 

ON   CONSTIPATION   OP  THE  BOWELS. 

Constipation  of  the  bowels  is  among  the  most 
common  evils,  as  respects  health,  among  the  inhabit- 
ants of  cities.  It  is  occasioned  in  part  by  their  diet, 
but  probably  much  more  by  their  sedentary  habits. 
The  same  habits  induce  the  same  evil  among  persons 
living  in  the  open  country.  The  great  extent  of  this 
evil  is  shown  by  the  multitude  of  remedies  for  it ;  of 
quack  remedies,  the  sale  of  which  has  enriched  their 
proprietors.  It  is  not  strange  that  persons,  unin- 
formed on  this  subject,  and  experiencing  daily  the 
evils  of  constipation,  should  employ  the  pills  and 
draughts  advertised  and  puffed  by  their  mercenary 
proprietors.  Why  should  we  speak  with  reproach  of 
these  persons?  The  efficient  elements  in  most  of 
their  patent  medicines  are,  I  suppose,  the  same  which 
are  employed  by  regular  physicians.  Most  of  them 
are  valuable  articles,  and  some  are  exceedingly  well 
adapted  to  the  purpose  in  view.     The  objections  to 


272  ON   CONSTIPATION   OF  THE   BOWELS. 

them  are  that  they  are  used  without  discrimination  as 
to  the  cases,  for  which  thej  are  respectively  best 
fitted;  and,  what  is  much  worse,  the  sufferers  are 
induced  to  take  medicine  instead  of  relying  on  diet 
and  regimen,  the  more  natural  modes  of  relief 

The  tendency  to  constipation  is  constitutional  in 
some  persons.  Whether  it  is  derived  from  some  pecu- 
liarity of  structure,  or  whether  connected  with  some 
modification  of  the  vital  powers,  I  am  not  prepared  to 
say.  There  are  men  whose  external  appearance  is 
modified  by  this  deep  trouble,  or  at  least  I  fancy  so. 
You  may  meet  such  a  one  daily  in  the  street,  moving 
with  a  regular  but  rather  slow  gait,  thin,  bony,  look- 
ing down,  his  body  slightly  bent  forward,  having  an 
anxious  countenance,  with  an  expression  as  if  worn  by 
a  hidden  grief;  with  a  skin  dry  and  somewhat  coarse 
or  rough,  and  a  dull  complexion,  rarely  showing  any 
•red  color.  This  melancholy-looking  man  attends  to 
business,  and  very  probably  is  growing  rich.  In 
conversation  you  find  him  more  cheerful  than  you  had 
anticipated,  and  quite  bright  at  times.  But  you  dis- 
cover that  he  is  limited  in  all  his  conduct,  not  willing 
to  eat,  drink,  or  sleep,  out  of  his  own  house ;  and 
reminding  you,  perhaps,  of  a  horse  tethered  out.  You 
may  help  such  a  man,  but  you  cannot  make  him 
anew. 


ON   CONSTIPATION   OF  THE   BOWELS.  27B 

What,  then,  shall  we  saj  to  one  habitually  consti- 
pated in  the  bowels  ?  We  must  make  him  acquainted 
with  the  causes  which  have  produced  the  evil,  and 
with  the  hygienic  rules  adapted  to  overcome  it.  First, 
a  laxative  diet  should  be  directed.  Among  the  articles 
adapted  to  this  purpose,  coarse  bread,  bread  made  from 
meal,  and  not  from  the  fine  flour  of  the  grain,  may, 
perhaps,  be  called  the  principal.  In  the  fine  flour  we 
have  the  nutritious  portion  of  the  seeds,  which  has 
been  procured  by  sifting  it  from  the  meal.  In  this 
case  the  hull  is  left  on  the  sieve.  For  nourishment 
alone  this  hull  is  of  very  little  value ;  but  far  other- 
wise when  we  take  into  view  its  effect  on  the  bowels. 
The  more  coarse  the  meal  the  better  for  the  purpose 
now  in  view.  Indeed,  it  is  found  better  to  employ 
the  wheat  simply  cracked.  This  cannot  be  made  into 
bread,  but  if  soaked  from  two  to  four  hours  in  warm 
water,  so  as  to  make  a  species  of  mush,  the  effect  of 
this  preparation  on  the  bowels  is  very  great.  It  is, 
however,  an  article  which  some  stomachs  do  not  well 
bear.    . 

I  cannot  pass  by  my  notice  of  this  article  without 
stating  the  obligations  our  community  is  under  to  my 
friend.  Dr.  John  C.  Warren.  We  had  been  in  the 
habit  of  employing  rye  meal,  and  sometimes  Indian 
meal,  as  laxative  articles,  and  had  thought  that  rye 


274  ON   CONSTIPATION   OF  THE   BOWELS. 

had  some  peculiar  property  of  this  kind.  It  was 
known  that  wheat  was  a  better  grain  for  nutriment 
than  the  rye  or  maize ;  but  wheat  being  used,  by  us 
in  New  England,  only  in  the  state  of  fine  flour,  it  was 
regarded  as  a  constipating  article.  Many  years  ago 
Dr.  Warren  recommended  the  bread  made  from  the 
wheat  meal,  sweetened  with  molasses.  This  bread 
got  the  name  of  dyspepsy  bread ;  a  name  given  to  it, 
I  believe,  by  the  bakers.  It  was  introduced  not  be- 
cause it  was  adapted  to  pure  dyspepsy,  but  as  a  remedy 
for  habitual  constipation.  It  is  true  that,  when  this 
bread  overcame  the  latter  complaint,  dyspepsy  in  cer- 
tain cases  was  removed,  or  alleviated,  showing  that  it 
was  caused  by  the  constipation.  Some  years  after  this, 
the  same  distinguished  gentleman  introduced  the  use 
of  groats,  or  cracked  wheat,  of  which  I  have  spoken 
above. 

The  advantage  of  having  bread  of  a  laxative  charac- 
ter is,  that  this  article  is  in  such  constant  use.  It 
enters  with  most  persons  into  every  meal,  and  often 
in  a  large  proportion  to  other  articles. 

There  is  another  form  in  which  the  meal,  or  coarse 
flour,  may  be  emploj^ed  with  advantage,  especially  by 
those  who  cannot  afford  to  use  expensive  fruits.  This 
is  mush^  or  hasty-pudding,  made  from  any  of  the 
grains,  the  rye  perhaps  being  the  best.     Butter  may 


ON    CONSTIPATION    OF   THE   BOWELS.  275 

be  used  with  this  pudding,  and  molasses  should  be 
added  as  increasing  its  value. 

White  mustard-seed  was  greatly  in  vogue  here,  some 
thirty  years  ago,  to  regulate  the  bowels,  and  thereby 
to  do  many  other  good  things.  It  was  recommended 
by  Cullen,  I  think,  but  was  revived  by  some  accident 
at  the  time  I  refer  to.  It  was  taken  in  doses  of  from 
one  to  eight  teaspoonfuls  a  day.  In  many  instances 
it  acted  very  kindly,  but  it  too  often  failed,  or  pro- 
duced some  inconveniences,  and  it  fell  into  disrepute. 
It  should  not,  however,  be  quite  forgotten. 

The  articles  we  call  fruits  are  most  of  them  very 
useful  and  very  agreeable  remedies  for  the  difficulty 
we  have  in  view.  Generally  speaking,  those  which 
are  succulent  and  tender  are  to  be  preferred;  and 
those  which  are  sweet  are,  perhaps,  rather  better  than 
such  as  are  acid.  To  this  last  remark  there  are  some 
exceptions.  Beginning  with  the  berries,  which  we 
find  in  the  summer,  in  our  climate,  we  go  on  to  the 
pears  and  apples  in  the  autumn.  As  these,  the  apples 
especially,  last  through  the  winter  and  spring,  we  get 
a  supply  of  fruit  for  most  of  the  year.  Of  the  pears, 
those  which  are  hard  are  not  very  valuable,  if  they 
are  at  all  so.  The  apple  may  be  used  without  cook- 
ing, by  many  persons;  but  they  are  better  for  all, 
especially  for  those  with  tender  stomachs,  after  being 


276  ON    CONSTIPATION   OF   THE   BOWELS. 

cooked.  Thej  should  be  cooked  in  their  skins,  that 
there  may  be  the  least  possible  loss  of  their  juices. 
The  good  pears  are  too  tender  to  make  this  necessary, 
but  they  are  not  injured  by  cookery.  One  advantage 
of  cooking  these  fruits  is,  that  the  stomach  will  bear 
more  of  them,  than  when  in  the  crude  state.  For  the 
purpose  we  have  in  view,  the  sweet  apples  are  rather 
better  than  others.  It  is  remarkable,  however,  that 
some  dyspeptics  can  bear  a  sharp  acid  apple  better 
than  a  sweet  one.  The  same  persons  will  bear  ripe 
currants  better  than  the  sweet  berries.  This  will  not 
seem  so  strange,  if  you  bring  to  mind  that  the  acidity 
of  the  stomach,  which  troubles  dyspeptics,  is  that 
which  arises  from  fermentation  of  the  food.  It  may 
be  produced  by  acids  taken  into  the  stomach,  especially 
those  of  unripe  fruits ;  but  not  so  readily  by  the  acid 
of  a  mature  fruit,  such  as  currants  are  in  tb*i  last  week 
of  July  and  in  August.  Looking  for  fruits  at  the 
different  seasons  of  the  year,  I  have  provided  for  all 
except  the  last  half  of  the  spring,  and  the  first  month 
of  the  summer.  But  all  persons  cannot  command  the 
delicate  fruits.  In  the  absence  of  these,  oranges  may 
be  resorted  to.  These  are  found  among  us  at  all 
seasons;  but  the  best,  the  most  mature,  are  to  be 
found  in  the  spring.  We  have  also  the  resource  of 
the  dried  foreign  fruits,  at  all  seasons.     The  most 


ON   CONSTIPATION    OF   THE   BOWELS.  27T 

valuable  of  these  are  figs  and  prunes.  The  latter  are 
made  better  by  steaming. 

I  think  the  best  time  for  the  use  of  fruit  is  at 
breakfast,  though  it  may  be  taken  at  dinner  if  proper 
room  is  allowed  for  it.  The  most  agreeable  time  for 
oranges  is  before  sitting  down  at  the  breakfast-table. 
Two  of  them  taken  at  this  time  are  all-sufficient  in 
many  instances.  I  must  not  omit  the  rhubarb  plant, 
which  resembles  the  acid  fruits.  This  may  be  used  in 
May,  and  continued  tilt  midsummer.  It  should  be 
stewed  with  sugar,  and  taken  at  breakfast  or  dinner. 
Though  this  article  is  called  the  pie-plant,  let  it  be 
noted  that  the  pie-crust  is  not  essential  to  it ;  and  to 
those  of  tender  stomachs  it  is  injurious. 

Thirdly.  Vegetable  food  generally  is  more  laxative 
than  animal  food.  This  is  particularly  true  of  the 
tender  and  succulent  vegetables.  There  are  two  arti- 
cles, which  come  under  the  name  of  vegetables  at  our 
tables,  which  are  especially  useful,  and  which  in 
reality  are  fruits.  These  are  the  squash,  the  winter 
squash  especially,  and  the  tomato. 

Fourthly.  To  the  foregoing  I  must  add  that  ole- 
aginous and  fatty  articles  have  a  laxative  effect.  The 
only  vegetable  oil  we  are  accustomed  to  is  that  from 
the  olive,  much  more  used  in  other  lands  than  in  ours, 
•and  certainly  of  great  value.  "We  get  a  vegetable  oil 
24 


278  ON   CONSTIPATION   OF   THE   BOWELS. 

in  the  nuts,  especially  in  that  called  the  oil  or  butter 
nut.  To  those,  who  have  not  access  to  other  laxative 
food,  this  nut  may  be  found  very  useful.  Animal  fat 
is  serviceable  in  the  same  way,  and  pork  is  the  best 
article  of  this  kind,  on  account  of  its  fat.  I  know  that 
this  is  contemned,  and  even  thought  injurious,  by 
many  persons  who  are  not  Jews.  To  some  stomachs 
it  certainly  is  offensive,  even  though  it  be  of  the  best 
quality.  But  to  many  persons  our  New  England 
corn-fed  pork  is  easy  of  digestion,  highly  agreeable, 
and,  as  the  phrase  is,  very  wholesome.  That  is  the 
term  which,  in  my  early  days,  many  delicate  persons 
employed,  when  they  meant  that  the  article  was  good 
for  the  bowels.  Let  me  here  mention  another  article, 
on  which  the  polite  are  apt  to  frown,  and  which  we 
can  hardly  recommend  to  young  ladies ;  this  is  the 
onion,  of  which  I  am  reminded  by  mentioning  pork 
It  is  quite  valuable  to  those  who  cannot  bear  the 
acescent  vegetables.  There  is  still  another  useful 
vegetable,  scarcely  admitted  on  genteel  tables,  or  not 
without  some  apology.  I  refer  to  beans.  The  objec- 
tion to  them  is  that  they  often  cause  flatulence.  For 
some  persons  this  is  a  sufficient  objection,  in  whatever 
way  the  article  is  prepared.  But  most  persons  can 
tear  beans  very  well  if  they  be  well  cooked.  They 
should  be  boiled  so  as  to  be  thoroughly  tender,  and 


ON    CONSTIPATION   OF   THE    BOWELS.  2T9 

then  baked  slowlj,  but  not  so  as  to  be  quite  dry. 
Some  black  pepper  may  be  added  to  them.  Pea-soup 
is  still  another  dish  to  be  had  in  respectful  remem- 
brance. Both  the  peas  and  the  beans  are  wholesome 
to  some,  though  not  to  all  persons. 

I  have  mentioned  a  variety  of  articles  for  the  pur- 
pose in  view,  and  it  is  desirable  to  have  a  variety  to 
choose  from.  I  have,  however,  omitted  some  which 
miglit  be  mentioned.  Some  are  very  useful  to  one 
person,  and  are  not  at -all  so  to  another.  People  get 
tired  if  confined  too  much  to  the  same  article,  and 
want  a  variety  to  suit  the  palate.  Lastly,  one  may 
be  procured  when  others  cannot. 

It  is  not  to  be  understood  that  persons  of  constipated 
habits  should  be  confined  to  the  articles  pointed  out 
above.  On  the  contrary,  these  should  be  taken  with 
others,  more  or  less,  as  the  case  may  require  at  dif- 
ferent periods.  But  none  of  them  are  to  be  relied  on 
as  medicines  for  a  temporary  purpose.  Generally, 
their  good  effects  do  not  show"  themselves  until  they 
have  been  taken  for  three  or  four  days  in  succession. 

I  have  treated  of  the  diet  fitted  to  obviate  habitual 
eostiveness.  Next  to  this  should  be  placed  bodily 
exercise.  In  many  instances  this  is  all  that  is  wanted. 
Care  in  diet  is  seldom  sufficient  without  it.  I  say  to 
the  sufferer  under  constipation,    "  Get  exercise  any 


280  ON   CONSTIPATION   OF   THE   BOWELS. 

how,  in  any  mode ;  but,  if  you  can,  let  it  be  on  your 
feet.  Walk  two  hours  every  day,  and  as  many  hours 
as  you  can  on  a  holiday.  It  is  best  to  walk  with  an 
object,  if  possible.  It  is  best,  also,  to  get  one  good 
walk  soon  after  breakfast ;  but  walk  in  the  eveninoj  if 
you  cannot  get  leisure  at  other  parts  of  the  day." 
Walking  is  better  than  riding  or  driving  for  the  pur- 
pose now  in  view ;  but  circumstances  sometimes  forbid 
this,  such  as  lameness  of  one  kind  or  another.  Then, 
if  possible,  let  the  patient  ge^  on  horseback.  In  all 
this  I  have  reference  to  citizens^  the  inhabitants  of 
cities,  or  of  large  and  busy  towns.  A  resident  in  the 
country,  who  does  not  get  his  living  by  labor  iii  the 
open  air,  more  than  half  the  year  may  resort  to  gar- 
dening. This  is  the  most  luxurious  exercise  one  can 
have,  if  he  has  any  taste  for  the  pursuit.  There  is 
one  other  mode  of  exercise,  which  may  be  enjoyed 
wherever  there  is  water  at  hand.  This  is  rowing  in  a 
boat.  Though  the  oarsman  is  not  on  his  feet,  he 
brings  all  parts  of  the  body  into  use.  This  exercise 
seems  to  belong  to  our  sex,  but  it  may  be  allowed  to 
the  other,  when  they  are  in  secluded  places ;  and  some 
of  them  know  how  to  excel  in  this  as  they  do  in  most 
handiworks  which  they  undertake. 

Many  persons  learn  for  themselves  the  influence  of 
habit  in  keeping  up  the  regular  action  of  the  bowels ; 


ON   CONSTIPATION   OF  THE  BOWELS.  281 

but  they  do  not  always  learn  this  before  tlie  middle 
of  life.  The  morning,  soon  after  breakfast,  in  the 
majority  of  cases,  is  found  the  most  convenient  time 
for  this  purpose ;  and  almost  any  one,  by  a  little  care, 
may  avail  himself  of  the  readiness  of  the  human  body 
to  be  influenced  by  habit,  so  as  to  fix  on  such  a  part 
of  the  day  as  he  pleases.  Persons  who  are  much 
troubled  by  hemorrhoids,  or  by  prolapsus  ani,  will 
find  it  best  to  get  their  evacuations  just  before  bed- 
time. The  advantage  is  that  such  persons  derive 
benefit  from  assuming  the  horizontal  position  for  a 
time  after  an  alvine  dejection.  I  must  give  a  cau- 
tion connected  with  this  subject.  One  should  not 
allow  himself  to  strain,  nor  to  hurry  himself  from  a 
regard  to  habit,  nor  for  any  other  reason.  In  this 
way  he  may  induce  hemorrhoids,  or  prolapsus.  These 
are  great  evils,  of  which  few  persons  are  aware  except 
those  who  have  suffered  them. 

It  is  best  to  get  a  dejection  from  the  bowels  once  a 
day.  There  are  some  who  get  two  a  day,  and  feel  the 
better  for  it;  but  they  are  rare  exceptions.  One 
should  strive  to  get  one  by  all  reasonable  means ;  but 
persons  of  infirm  health  are  sometimes  unduly  anxious 
on  the  subject.  They  are  made  fidgety  and  really 
unhappy  if  they  miss  a  day.  I  believe  it  conduces  to 
good-humor  to  be  regular  on  this  point ;  but  I  could 
24* 


282  ON  CONSTIPATION   OF  THE  BOWELS. 

bring  good  evidence  to  show  that  a  man  may  have  a 
verj  good  share  of  health,  and  a  great  abundance  of 
generous  good-humor,  though  he  should  relieve  the 
bowels  only  once  in  four  days.  Such  a  case  is  singu- 
lar, no  doubt,  but  there  are  many  instances  of  persons 
who  have  very  comfortable  health,  while  they  get 
relief  only  once  in  forty-eight  hours.  Nature  does 
not  lay  down  universal  rules  on  all  points. 

The  great  object  of  maintaining  sufficient  evacua- 
tions is  not  attained  by  all  men,  though  they  follow 
the  directions  above  given  with  exactness.  This  some- 
times arises  from  a  constitutional  peculiarity,  but  for 
the  most  part  it  is  produced  by  a  long  neglect  of  the 
hygienic  laws.  When  this  neglect  has  arisen  from 
wilfulness,  and  not  from  ignorance,  you  may  say  a 
man  deserves  the  punishment  which  nature  inflicts 
upon  him.  If  this  be  true,  it  is  not  the  business  of 
the  physician  to  leave  him  to  his  fate.  He  must  try 
to  alleviate  the  evils,  however  induced,  and  gently,  but 
firmly,  to  persuade  his  patient  to  return,  as  far  as  he 
can,  to  the  right  path. 

What  now  shall  we  do  to  the  patient  who  cannot 
overcome  the  habit  of  constipation  by  such  means  as 
have  been  pointed  out ;  by  diet  and  regimen  ?  The 
reply  is,  in  general  terms,  that,  when  we  are  obliged 
to  resort  to  art,  we  must  imitate  nature  as  nearly  as 


ON  CONSTIPATION   OF  THE   BOWELS.  283 

we  can.  Bj  imitating  nature  in  this  case,  I  mean  that 
we  should  strive  to  bring  about  the  end  in  the  quiet 
and  easy  manner  in  which  nature  does  it.  Further, 
as  men  in  health  do  not  effect  the  object  in  view  per- 
fectly, and  equally,  every  day,  we  must  be  satisfied 
if,  by  art,  we  can  succeed  pretty  well  on  the  whole, 
though  not  every  day.  By  trying  to  keep  up  to  the 
mark,  without  failure,  we  shall  be  liable  often  to  over- 
step it. 

The  simplest  and  safest  of  remedies  for  habitual 
costiveness,  in  a  large  proportion  of  instances,  is  the 
injection  into  the  rectum  of  cold  water,  to  the  amount 
of  one  or  two  gills.  This  remedy  may  be  used  every 
day,  with  ordinary  care,  for  many  years,  without  any 
injury.  It  is  successful  in' the  cases  where  the  faecal 
mass  is  brought  to  the  rectum  and  delayed  there.  If 
the  failure  takes  place  above,  so  that  the  faeces  are  not 
brought  down,  this  remedy  will  not  answer  the  pur- 
pose. It  is  true  that,  in  certain  extraordinary  cases 
of  constipation,  benefit  has  been  derived  from  injecting 
three  or  four  pints  of  water.  In  this  way  the  fluid 
may  be  made  to  pass  up  the  colon,  and,  probably,  even 
to  the  coecum.  But  that  is  not  a  method  to  be 
adopted  for  ordinary  cases,  and  it  is  of  these  I  am 
treating. 

In  the  cases,  for  which  the  daily  or  frequent  use  of 


284  ON   CONSTIPATION   OF  THE  BOWELS. 

injections  can  be  adopted  with  success,  it  is  proper  to 
give  instructions  for  the  convenient  management  of 
the  process.  Few  men  will  adhere  to  this  remedy,  if 
they  must  be  put  to  great  trouble  every  time  they  use 
it.  The  first  question  is,  what  instrument  shall  be 
used  ?  I  think  it  very  certain  that  the  best  instru- 
ment, to  be  used  on  one's  self,  is  a  metallic  syringe 
with  a  curved  pipe.  This  should  be  kept  with  pipe 
screwed  on  to  the  cylinder,  so  as  to  be  ready  for  use 
without  delay.  After  it  has  been  used,  it  requires  only 
to  be  made  clean  externally.  Plain  water  only  being 
used,  it  does  not  require  any  care  for  the  internal 
part,  except  to  throw  out  any  remnant  of  the  water 
which  may  be  in  it.  Such  instruments  are  to  be 
found  among  us,  holding  nominally  six  ounces,  but 
really  holding  about  four  ounces.  They  are  better 
than  larger  ones,  though  they  must  sometimes  be  used 
twice,  because  they  are  as  large  as  it  is  convenient  to 
handle.  If  you  would  have  the  best,  get  a  philosophi- 
cal instrument-maker  to  supply  you  a  brass  syringe 
furnished  with  a  metallic  piston.  The  pipe  should 
be  silvered  over.  There  are  other  instruments,  which 
may  appear  to  you  better  at  first  sight,  but  they  do 
not  wear  so  well.  This  is  true  of  all  which  have 
flexible  tubes,  or  India  rubber  in  any  part  of  them. 
They  get  out  of  order  very  often ;  they  require  more 


ON   CONSTIPATION   OF   THE   BOWELS.  285 

care  each  time  they  are  used,  and  the  use  of  them  is 
not  attended  with  the  same  facility.  For  a  sick  per- 
son, lying  in  bed,  Mawe's  instrument,  or  one  on  the 
same  principle,  is  better  than  the  syringe  above  de- 
scribed. The  French  instrument,  which  goes  ojBf  upon 
pressing  a  spring,  is  very  convenient  in  some  respects. 
It  is  of  comparatively  little  moment  what  instrument  is 
employed,  if  there  be  a  valet  de  chambre,  or  a  waiting 
maid  to  take  care  of  it.  Not  so  when  one  takes  the 
whole  matter  into  his  own  hands.  I  will  not  omit  one 
hint  more,  although  one  does  not  want  to  dwell  too  long 
on  the  affairs  now  under  consideration.  This  is,  that 
it  is  best  to  pass  the  instrument  sideways  under  the 
body,  sitting  in  a  water-closet,  or  on  the  appropriate 
cabinet,  and  then  rising  up  to  bring  the  handle  of  the 
syringe  against  the  wall  of  the  apartment ;  then,  by 
carrying  the  body  gently  toward  the  w^all,  the  piston 
may  be  pressed  firmly  and  yet  gently  into  the  cylin- 
der. 

The  treatment  just  stated  is  insufficient  for  those 
cases,  m  which  the  faeces  are  not  brought  down  to  the 
rectum.  Besides,  there  are  many  persons  who  cannot 
succeed  in  using  injections,  and  more  who  will  not 
submit  to  the  trouble  of  this  simple  and  safe  remedy. 
We  must  then  administer  medicine,  and  in  doing 
this  our  object  should  be  to  employ  the  mildest  and 


286  ON   CONSTIPATION   OF  THE  BOWELS. 

safest  article  which  will  suffice.  If  there  were  one 
such  article,  which  would  prove  the  best  for  every 
case,  the  matter  could  be  easily  settled.  This  is 
what  is  pretended  by  every  quack,  who  advertises  his 
own  wonderful  discovery  of  a  pill,  or  powder,  for  this 
purpose.  And  the  patient,  who  has  found  an  article, 
which  suits  himself,  after  having  tried  a  dozen,  is 
very  apt  to  recommend  it  to  his  friends  as  fitted  for 
all  men.  We  doctors,  like  the  tailors,  find  that  coats 
of  the  same  size,  and  proportions,  and  fashion,  will 
not  suit  every  individual.  My  own  course  is  to  study 
the  circumstances  of  each  case,  and  endeavor  to  an- 
ticipate which  among  the  milder  cathartics  is  most 
likely  to  be  suitable  and  efficient.  I  say  suitable,  for 
the  article  must  be  one,  which  wiU  give  the  least 
inconvenience  as  to  the  taking  it,  and  in  its  efiects  on 
the  stomach  and  bowels.  I  say  efficient,  for  we  want 
an  article  which  shall  be  tolerably  sure  to  act  with 
regularity  as  to  time,  without  over-acting.  Persons 
who  might  be  relieved  by  injections,  but  who  will  not 
use  them,  will  probably  find  the  saline  medicines,  in 
small  doses,  but  largely  diluted,  the  most  suitable  for 
them.  Such  are  many  of  the  natural  mineral  waters, 
among  which  the  Congress  water  from  our  Saratoga  is 
as  extensively  famed,  and  as  justly,  as  any.  In  most 
instances  a  pint  of  this  water,  taken  before  breakfast, 


ON   CONSTIPATION   OF  THE   BOWELS.  287 

is  sufficient.  This  maj  be  divided  into  two,  or  more 
portions.  For  some  persons  a  quart  is  required ;  but 
here  we  must  watch  lest  there  be  some  harm  from  so 
large  a  potation.  It  is  true  that  there  is  scarcely  any 
liquid  of  which  so  much  can  be  taken  with  impunity 
as  these  natural  waters,  when  containing  a  due  quan- 
tity of  carbonic  acid.  Very  similar  in  their  effects  to 
these  waters  are  the  articles  known  as  Seidlitz  and 
Rochelle  powders.  The  most  convenient  of  these  arti- 
cles is  sold  under  the  name  of  Butler's  tasteless  Seidlitz 
powders.  A  common  soda  powder  is  enough  for  many 
persons.  I  ought  to  add  that  some  succeed  very  well 
with  a  cheaper,  though  less  agreeable  article.  This 
is  the  sulphate  of  magnesia,  or  any  similar  neutral  salt 
having  a  laxative  power,  taken  in  the  dose  of  a 
teaspoonful,  but  dissolved  in  half  a  pint  of  water. 
This  may  be  made  less  disagreeable  by  adding  sugar 
and  peppermint- water,  ginger,  or  some  other  aromatic. 
The  morning,  before  breakfast,  is  the  best  time  for 
using  any  of  the  articles  above  named.  The  break- 
fast may  be  taken  shortly  afterwards  without  any 
harm. 

From  various  causes,  perhaps,  none  of  these  saline 
articles  suit  some  individuals.  For  such  we  must 
furnish  a  medicine  of  greater  efficiency,  and  given  in  a 
smaller  compass.     These  are  required  especially  for 


288  ON   CONSTIPATION   OF   THE   BOWELS. 

those  whose  bowels  are  sluggish  ;  in  whom,  probably, 
there  is  a  great  delay  of  the  faeces  in  the  colon.  You 
will  find  some  delicate  and  feeble  women  in  this  class. 
In  them  it  would  seem  as  if  there  were  a  real  want  of 
muscular  power  in  the  coecum  and  colon ;  the  more 
when  there  is  not  any  aid  from  bodily  exercise.  But 
very  many,  who  require  similar  aid,  are  men  of  strong 
constitutions,  who  eat  and  drink  freely,  and  who  are 
fitted  for  hard  work,  but  do  not  indulge  themselves 
in  it.  In  these  cases  I  sometimes  suspect  that  one 
great  process  of  the  large  intestines  is  carried  too  far. 
The  absorbents  take  up  too  much  of  the  liquid  con- 
tained in  the  mass  brought  down  through  the  ileum. 

Among  the  very  convenient  and  efficient  medicines 
for  persons  of  this  class  is  aloes.  It  is  the  substantial 
part  of  Anderson's  pills,  which  have  had  the  most 
extensive  celebrity  among  the  English  and  their 
descendants  for  three  or  four  generations,  and,  I 
believe,  i*  enters  largely  into  many  other  patent 
articles  of  the  same  character.  It  is  ordered  as  a  shop 
medicine  in  the  regular  pharmacopoeias,  alone,  or  in 
combination,  in  the  form  of  pills ;  and  it  is  the  es- 
sential part  of  that  grand  old  domestic  tincture  known 
under  the  name  of  Elixir  Proprietatts.  So  far 
it  would  seem  that  aloes  would  meet  all  one's  wishes ; 
but  like  most  of  the  good  things  on  earth,  it  has  its 


ON   CONSTIPATION   OF   THE   BOWELS.  289 

defects.  I  do  not  refer  to  the  pain  it  sometimes 
causes  in  passing  the  bowels  ;  for,  though  it  has  this 
fault,  the  same  is  true  in  a  greater  degree  of  many 
other  articles  of  its  kind.  "What  I  do  refer  to  is  its 
tendency  to  produce  haemorrhoids.  This  is  true  of 
some  other  similar  articles,  but  not  to  the  same 
extent.  It  is  a  reason  for  using  this  medicine  watch- 
fully, and  for  forbidding  it  to  persons  who  have 
haemorrhoids,  or  any  other  disease  about  the  rectum. 
Rhubarb  is  another  article  employed  with  great  satis- 
faction by  many  persons.  Some  men  chew  it  daily, 
and  some  when  specially  needed ;  and  for  those,  who 
do  not  object  to  the  taste,  this  is  a  good  mode  of  using 
the  article.  The  nicest  pieces  are  of  course  selected, 
and  usually  the  Turkey  rhubarb  is  preferred  for  this 
purj)Ose.  The  medicine  may,  however,  be  made  into 
pills,  or  into  an  infusion,  and  be  combined  with  some 
aromatic  article.  The  tincture  is  valued  highly  by 
some  individuals,  but  it  is  objectionable  because  most 
persons  require  of  it  a  larger  quantity  than  it  is  wise 
to  administer  daily,  or  frequently,  of  a  spirituous 
article.  Rhubarb  more  often  causes  griping  than 
aloes.  I  ruight  go  on  to  mention  many  other  well- 
known  articles  for  the  purpose  in  view,  such  as  scam- 
mony,  colocynth,  sulphur,  magnesia,  etc.,  etc.  Sul- 
phur and  magnesia  are  comparatively  bulky  articles. 
25 


290  ON   CONSTIPATION   OF  THE   BOWELS. 

The  sulphur,  however,  is  now  and  then  found  to  an- 
swer very  well,  especially  for  persons  liable  to  hemor- 
rhoids. The  magnesia  is  a  favorite  with  many  per- 
sons subject  to  acidity  of  stomach.  It  is  not,  however, 
an  article  to  be  commended  for  frequent  use.  It  is 
sometimes  found  to  accumulate  in  the  intestines.  But 
an  evil  much  more  common  is  that  it  is  slow  in  opera 
tion,  often  keeping  up  an  uneasiness  for  many  hours, 
and  causing  many  small  dejections,  instead  of  one 
sufficient  one. 

It  has  been  found  that  a  combination  of  moderate 
cathartics  will  act  more  kindly  than  any  one  alone ; 
and  sometimes  a  powerful  article  may  enter  into  the 
mixture,  in  an  extremely  small  dose,  without  injury, 
and,  perhaps,  with  advantage.  It  is  a  convenience 
of  such  an  addition  that  we  can  get  a  sufficient  dose 
in  a  small  compass.  Gamboge  has  been  employed  in 
this  way.  I  am  not,  however,  disposed  to  favor  this 
article,  as  it  sometimes  proves  treacherous ;  that  is, 
it  will  act  with  undue  violence.  Strychnia  is  employed 
in  the  same  way  at  the  present  day,  and  with  care  it 
may  be  employed  with  advantage  in  cases  hard  to 
manage.  But  it  should  be  given  in  a  very  small  dose, 
not  more  than  one  twelfth  part  of  a  gi-ain  in  a  dose 
containing  other  articles.  After  trial  the  dose  of 
strychnia  may  be  increased.      When  it  is  used  two 


ON   CONSTIPATION   OF  THE   BOWELS.  291 

precautions  are  necessary;  one,  that  the  medicine 
should  be  prepared  very  faithfully,  by  a  responsible 
person,  to  insure  the  equal  distribution  of  the  strych- 
nia through  the  mass  into  which  it  enters ;  the  other, 
that  the  patient  should  be  apprised  of  the  properties 
of  the  article,  that  he  may  not  at  any  time  take  more 
than  the  dose  prescribed. 

We  should  rarely  employ  such  heroic  medicines. 
There  are  many  safer  combinations  than  those  into 
which  these  articles  enter.  There  is  one  in  our  phar- 
macopoeia, which  is  quite  equal  to  our  common  needs, 
when  faithfully  prepared.  This  is  the  compound  ex- 
tract of  colocynth.  Though  there  is  some  aloes  in 
this  article,  it  is  very  rarely  hurtful.  Indeed,  I  have 
never  been  satisfied  that  this  preparation  has  brought 
on  hemorrhoids  in  any  case.  This  may  receive,  in 
combination,  any  other  medicine  of  small  bulk  which 
the  occasion  calls  for.  There  is  one,  often  prescribed 
for  rheumatism,  which  acts  so  pleasantly  on  the  bowels 
that  I  think  it  would  be  frequently  employed,  if  it 
could  be  brought  into  a  small  bulk.  This  is  the  resin 
of  guaiacum,  of  which  the  dose  is  one  drachm.  It 
may  now  and  then  be  convenient  to  remember  this. 
It  should  not  be  taken  in  the  form  of  tincture,  as  the 
requisite  dose  would  contain  too  much  alcohol. 

I  have  been  treating  of  habitual  constipation.     We 


292  ON    CONSTIPATION   OF  THE   BOWELS. 

ineetj  occasionally,  instances  of  very  great  and  obsti- 
nate constipation,  wliicli  are  to  be  regarded  very  differ- 
ently. In  some  of  these  we  see  good  reason  to  suppose 
that  the  constipation  depends  on  some  organic  or  some 
mechanical  difficulty ;  or  on  inflammation  in  some 
part  of  the  intestines.  In  all  cases  of  peculiar  consti- 
pation, we  must  bear  in  mind  that  such  obstacles  may 
exist;  and,  if  so,  that  our  cathartics  would  not  only 
fail  to  do  good,  but  might  do  harm.  We  must,  there- 
fore, proceed  with  great  caution  and  circumspection, 
as  the  seaman  does  when  he  fears  sunken  rocks.  We 
should  examine  carefully  in  the  usual  seats  of  hernia. 
If  there  be  nothing  found  in  them,  we  should  ascertain 
whether  there  is  any  tender  spot  in  the  abdomen  upon 
slight  or  deep  pressure ;  whether  there  is  any  tumor 
or  indurated  organ  in  that  cavity  ;  and  whether  there 
are  such  constitutional  symptoms  as  attend  inflamma- 
tion. If  there  be  obstinate  vomiting,  our  fears  should 
be  more  awakened. 

If  we  find  no  evidence  of  such  local  difiiculties  as 
have  been  referred  to,  we  should  follow  the  plain  indi- 
cation to  purge  the  bowels.  We  should  try  the  safe 
remedies ;  that  is,  such  as  will  not  do  harm  if  they 
are  retained.  I  would  not,  therefore,  begin  with 
calomel,  unless  when  the  stomach  is  so  irritable  that 
H  is  not  likely  to  retain  other  medicines.     In  such  a 


ON   CONSTIPATION    OF   THE   BOWELS.  293 

case  one  or  two  doses  of  calomel  may  determine  the 
current  downward,  and  leave  the  way  open  for  more 
active  medicines.  You  may  be  surprised  that  I  say 
more  active  medicines ;  but,  in  truth,  calomel  is  slow 
in  its  operation ;  it  starts  the  mass,  but  does  not  carry 
it  through ;  so  that  I  often  compare  it  to  the  scraper 
used  by  the  chimney-sweep,  which  requires  a  brush 
after  it  to  bring  away  the  soot.  Besides  calomel,  other 
medicines  in  small  bulk  are  best,  when  the  stomach  is 
irritable.  The  compound  extract  of  colocynlh  is  a 
very  good  article.  But  after  these,  or  at  first,  if 
the  stomach  is  quiet,  castor  oil  is  the  most  appro- 
priate. This  medicine  excites  secretions  sufficient  to 
soften  the  faeces,  while  it  promotes  the  peristaltic 
motion,  so  as  to  carry  forward  any  mass  which  may 
have  accumulated.  The  neutral  salts  may  answer  the 
purpose ;  but  it  appears  to  me  that,  while  they  cause 
copious  watery  secretions,  they  do  not  so  act  on  the 
muscular  coat  as  to  insure  the  removal  of  the  solid 
matter.  Oftentimes  in  such  cases  there  is  a  difficulty 
in  keeping  the  medicines  upon  the  stomach.  Then 
we  may  resort  to  preparations  of  senna  or  jalap,  or 
both  together,  which  should  be  given  in  liquid  form, 
and  in  small  doses,  frequently  repeated.  There  is  an 
article,  which  I  introduced  into  v^se  at  our  hospital, 
well  known  among  us,  under  the  name  of  the  com- 
25* 


2M  ON   CONSTIPATION   OF  THE  BOWELS. 

found  infusion  of  senna.  Besides  the  senna,  it  has 
jalap,  supertartrate  of  potass,  and  manna,  in  its  com- 
position; and  with  these  the  compound  tincture  of 
senna.  Where  it  is  desirable  to  have  the  stimulus  of 
the  tincture,  this  preparation  may  be  used  with 
advantage ;  but,  otherwise,  there  is  a  more  modern 
preparation,  which  is  better.  This  is  the  fluid  extract 
of  senna.  One  advantage  of  this  extract  is,  that  in 
the  same  dose  it  is  about  twice  as  powerful  as  the  com- 
pound infusion  above  mentioned ;  a  great  advantage 
when  you  have  to  do  with  an  irritable  stomach.  Other 
articles  will  always  suggest  themselves,  when  there  are 
objections  to  the  above  named.  In  these  cases  we 
should  also  avail  ourselves  of  injections  into  the  rec- 
tum, which  should  be  large  in  quantity,  and  more  or 
less  stimulant,  as  circumstances  may  indicate.  I  shall 
mention  one  which  I  hold  in  high  estimation  in  all 
obstinate  cases ;  this  is  a  mixture  of  oil  and  water, 
with  soap  to  make  the  oil  miscible  with  the  water, 
and  to  break  it  up  into  small  globules,  without  so 
much  soap  as  to  make  the  oil  entirely  disappear.  In 
one  of  these  obstinate  cases  I  should  use  the  follow- 
ing :  —  take  a  heaping  tablespoonful  of  soft  soap,  half  a 
pint  of  olive  oil,  and  a  pint  and  a  half  of  warm  water, 
and  mix  them  thoroughly ;  the  whole  of  this  should 
be  used  at  once.     It  may  be  necessary  to  repeat  both 


ON   CONSTIPATION    OF   THE   BOWELS.  295 

the  purgative  medicines  and  the  enemata.  There  are 
cases,  mostly  in  persons  who  have  been  much  neg- 
lected, where  you  find  a  great  mass  of  faeces  impacted 
in -the  rectum.  In  these  it  is  best  to  resort  to  me- 
chanical means,  using  something  like  a  scoop  to  break 
up  and  dig  out  the  mass. 

Where  there  is  reason  to  suppose  that  there  is  a 
mechanical  obstacle,  analogous  to  hernia,  or  where  an 
inflamed  organ  constitutes  the  obstacle,  the  treatment 
must  be  varied  to  meet  the  circumstances.  To  go  into 
all  the  possible  circumstances  would  lead  me  too  far. 
I  will  say,  however,  that  where  there  is  reason  even 
to  suspect  an  inflammation  in  the  intestines,  blood- 
letting at  an  early  stage  is  the  most  important  remedy. 
It  serves  to  relieve  the  distress  and  to  liberate  the 
bowel ;  for  then  it  can  yield  to  the  effect  of  a  cathartic. 
Let  me  add  further,  that  in  blind  cases,  a  masterly 
inactivity  should  be  adopted.  This  requires  more 
true  courage  than  the  exhibition  of  the  most  heroic 
remedies. 

I  must  make  a  small  addition  to  this  long  letter, 
in  respect  to  diseases  of  the  rectum.  I  have  ref- 
erence to  hemorrhoids,  prolapsus  ani,  and  the  fissure, 
or  crevasse  of  the  rectum.  "What  I  wish  to  say  in 
regard  to  these  is,  that  the  greatest  and  most  perma- 
nent relief  may  often  be  obtained  by  an  operation. 


296  ON   CONSTIPATION   OF   THE  BOWELS. 

As  I  have  not  practised  surgery  for  nearlj  half  a 
century,  I  shall  not  be  suspected  of  wishing  to  exalt 
my  own  art.  I  have,  however,  called  in  the  aid  of  a 
skilful  surgeon  in  many  such  cases ;  a  number  of 
these  have  been  ladies,  who  have  subsequently  ex- 
pressed great  gratitude  to  me  in  consequence  of  the 
relief  they  have  obtained.  It  is  in  bad  cases  of  piles, 
external  or  internal,  most  especially  when  bleeding,  that 
I  have  found  surgery  thus  useful.  In  milder  cases  other 
well-known  remedies  succeed,  into  the  consideration  of 
which  I  shall  not  enter.  In  all  cases  of  prolapsus  and 
of  fissure  I  believe  the  sooner  an  operation  is  performed 
the  better.  If  the  prolapse  is  slight,  the  slighter  will 
be  the  operation,  and  with  proper  subsequent  care 
there  will  be  an  end  of  the  trouble.  The  subsequent 
care  has  reference  to  the  habitual  costiveness,  to  which 
the  tendency  is  increased  by  the  operation.  Diet  will 
often  overcome  this  after  a  few  weeks  or  months  ;  for, 
at  first,  some  gentle  laxative  medicine  is  required. 
But,  at  the  worst,  a  daily  injection  of  cold  water  may 
become  necessary.  After  a  little  habit  this  is  found 
not  a  very  troublesome  affair,  and  the  relief  from  the 
daily  annoyance  of  the  disease  is  beyond  all  price. 


LETTER    XV. 

ON   BILIOUS    DISEASES,    BILIARY   AND   URINARY   CAL- 
CULI,   AND    IRRITABLE   BLADDER. 

In  this  letter  I  have  a  little  to  offer  on  several  dif- 
ferent topics,  but  only  a  little.  You  hear  eveiy  day 
of  bilious  diseases,  and  diseases  of  the  liver.  Mes- 
merizers,  and  people  of  that  sort,,  accuse  the  liver  very 
frequently.  I  have  often  said  that  the  liver  is  like 
the  greatest  rogue  in  the  village,  who  is  accused,  upon 
suspicion,  wherever  any  mischief  has  been  done.  Such 
an  one  has  so  bad  a  reputation,  that  it  is  not  thought  a 
libel  if  you  speak  ill  of  him.  I  may  almost  say  that 
there  are  some  among  the  brethren,  who  hardly  think 
of  the  liver  but  as  an  organ  for  the  production  of  dis- 
ease. When  I  began  practice,  some  of  my  elder 
brethren,  excellent  men  too,  almost  always  referred 
an  obscure  chronic  disease  to  the  liver.  They  talked 
familiarly  of  old  liver  cases,  without  a  definite  notion 
of  any  particular  disease.  I  believe  that  some  of  the 
mesmerizers  talk  of  the  liver  as  being  rotten,  or  all 


298  ON  BILIOUS  DISEASES,    ETC. 

decayed :  states  of  the  organ  which  the  morbid  anato- 
mists, who  cannot  see  through  the  parietes  of  the 
abdomen,  are  not  well  acquainted  with. 

The  term  bilious  is  applied  indiscriminately  to  dis- 
eases, in  which  much  bile  is  discharged  from  the 
stomach  or  bowels,  and  to  those,  in  which  the  bile  is 
entirely  wanting  in  the  alvine  discharges.  In  both 
cases,  calomel  and  blue  pill  are  regarded  as  the  appro- 
priate remedies.  Now,  the  liver  is  an  organ  subsidiary 
to  the  stomach  and  intestines,  just  as  the  salivary 
glands  are  to  the  mouth.  In  the  greatest  proportion 
of  cases,  which  are  called  bilious,  the  real  disease  is 
in  the  stomach  or  intestines ;  and  by  this  the  liver  is 
provoked  to  pour  out  its  secretion,  just  as  the  salivary 
glands  are  when  any  acrid  matter  is  taken  into  the 
mouth,  or  when  its  mucous  membrane  is  inflamed. 
In  these  cases  calomel  is  often  very  useful :  but  it 
should  not  be  given  merely  because  there  is  too  much 
bile,  or  too  little.  It  is  undoubtedly  true  that  a  disease 
in  the  liver  itself  may  be  attended  by  an  increased 
secretion  of  bile,  or  more  frequently  by  a  deficiency 
of  this  secretion.  Chronic  diseases  in  the  liver  are 
not  rare  among  us,  though  not  very  frequent;  but 
acute  diseases  of  the  liver  have  very  seldom  occurred 
under  my  observation.  I  have  known  acute  hepatitis 
sufficiently  well   marked.     I   have,   also,    sometimes 


299 


met  with  abscesses  in  the  liver,  the  existence  of 
which  was  not  suspected  during  life.  There  is  no 
doubt  that  hepatitis  is  much  more  common  in  warm 
climates,  than  with  us ;  and  this  is  so  especially  in 
Bengal.  But  even  there  the  doctors  are  too  ready  to 
believe  that  "it  is  the  liver,"  if  there  is  any  pain  in 
the  right  side.  A  few  years  ago  a  young  friend  of 
mine  was  there  with  a  pleurisy  attended  by  effusion 
in  the  right  thorax,  and  was  treated  unhesitatingly  as 
having  hepatitis.  Not  mending  under  the  treatment, 
he  went  over  land  to  England,  and  hurried  home  by  a 
steamer.  Here  the  true  disease  was  discovered  at 
once.  This  was  not  done  by  guessing,  but  by  the  use 
of  the  senses. 

I  have  thought  it  useful  to  make  these  general 
remarks,  although  I  do  not  design  to  go  into  the 
diseases  of  the  liver  generally.  But  I  wish  to  make 
some  observations  on  jaundice^  as  one  of  its  most 
common  diseases. 

The  name  jaundice  is  sometimes  loosely  applied  to 
cases  where  there  is  only  a  yellowness  of  the  skin. 
In  jaundice  proper  there  is  not  only  the  golden  color 
of  the  skin,  but  also  high  colored  urine,  staining  the 
linen  yellow,  and  an  absence  of  bile  in  the  faeces. 
This  last  is  essential.  These  symptoms  seem  to  show 
that  there  is  an  obstruction  in  the  common  bile  duct. 


300 


I  know  that  this  is  denied ;  and  there  may  be  cases 
in  which  the  obstruction  is  not  discovered  after  death. 
It  isj  however,  clear,  when  these  symptoms  exist,  that 
the  bile  does  not  flow  into  the  intestines.  The  causes 
of  the  obstruction  are  very  various,  and  we  have  not 
any  certain  means  of  distinguishing  them  during  life. 
They  are  sometimes  such  as  cannot  be  overcome.  An 
organic*  disease  at  the  right  end  of  the  pancreas  may 
involve  the  common  bile  duct,  and  close  it  perfectly. 
Large  calculi  and  other  causes  may  do  the  same. 
But  there  are  some  causes  of  obstruction,  which  are 
removed  by  the  spontaneous  action  of  the  parts.  One 
of  these  is  a  gall-stone  stopping  the  passage  and  at 
length  finding  its  way  into  the  duodenum.  I  have 
long  suspected  that  another  is  a  disease  of  the  mucous 
membrane  of  the  common  duct  in  some  part  of  its 
course,  or  at  its  mouth.  It  is  very  probable  that  this 
difficulty  is  combined  with  the  calculus  in  some  in- 
stances, and  that  when  the  vascular  fulness  of  the 
mucous  membrane  has  subsided,  the  calculus  is  allowed 
to  pass.  Though  I  entertained  this  opinion,  it  had 
never  occurred  to  me  to  employ  bleeding  for  relief, 
until  led  to  it  by  accident.  About  twenty  years  ago 
I  had  a  patient  at  the  hospital,  convalescent  from 
typhoid  fever,  who  was  taken  with  pain  in  the  region 
of  the  liver,  and  with  other  symptoms  of  inflammation, 


ON   BILIOUS   DISEASES,    ETC.  301 

not  very  severe ;  but  with  these  there  were  the  signs 
of  icterus.  On  account  of  the  inflammatory  symp- 
toms I  applied  leeches  on  the  right  hypochondrium. 
Within  forty-eight  hours  the  bile  flowed  through  the 
intestines,  and  the  symptoms  of  inflammation  subsided. 
This  did  not  prove  that  my  opinion  was  correct,  but 
it  gave  me  a  hint.  Not  long  after,  I  employed  the 
same  remedy  in  a  case  of  icterus,  also  at  the  hospital, 
and  here,  also,  there  was  entire  relief  within  forty- 
eight  hours.  From  that  time  I  have  continued  to  use 
this  remedy.  I  have  tried  it  in  cases  at  all  periods 
of  the  disease,  from  the  second  day  to  the  fifth  week. 
Many  of  these  cases  have  been  seen  in  consultation. 
In  three  instances,  and,  I  believe,  only  three,  the 
relief  has  not  followed  this  treatment,  and  yet  the 
patient  has  subsequently  recovered.  In  all  the  other 
cases,  where  it  has  failed,  the  disease  has  proved  fatal. 
In  most  of  them,  examinations  after  death  have  shown 
some  obstructions,  which  could  not  be  overcome. 
Indeed,  this  has  been  true  of  all,  in  which  examinations 
were  allowed.  I  have  not  a  record  of  my  cases,  but 
the  instances  in  which  leeches  have  been  followed  by 
relief  cannot  be  less  than  twenty.  I  have  failed  to 
give  immediate  relief,  to  an  adult,  where  I  have 
used  less  than  eight  good  leeches.  But  this  has 
happened,  I  believe,  only  twice,  and  in  those  instances 
26 


802  ON   BILIOUS   DISEASES,    ETC. 

a  second  leeching  has  been  followed  by  relief.  The 
relief  has  been  shown  by  the  appearance  of  bile  in  the 
faeces  within  forty-eight  hours  after  the  leeches. 
Now,  I  think  it  cannot  be  considered  accidental  that 
relj^f  should  follow  within  this  space  of  time,  when  the 
remedy  has  been  employed  at  such  various  periods  of 
the  disease.  I  do  not  ask  any  one  to  admit,  and  I  am 
not  sure  myself,  that  this  proves  that  the  disease  con- 
sists in  an  inflammation  of  the  bile-duct ;  but  certainly 
it  is  a  good  ground  on  which  to  employ  the  remedy, 
until  something  better  is  pointed  out.  I  am  aware 
that  icterus  goes  off  spontaneously  in  some  cases,  and 
probably  it  would  have  done  so  in  many  of  mine ; 
but  not  just  at  the  periods  when  it  did.  It  has  some- 
times been  objected  to  this  treatment  that  it  is  debili- 
tating. I  will  take  this  occasion  to  say  that  I  think 
debility,  and  that  of  a  bad  kind,  is  much  oftener  pro- 
duced by  powerful  drugs,  than  by  blood-letting  of  any 
kind. 

Though  I  now  feel  almost  hopeless  when  jaundice 
does  not  yield  to  the  leeches,  yet  I  do  not  say  that 
nothing  more  should  be  tried.  I  should  not  be  willing, 
if  it  were  my  own  case,  to  omit  the  trial  of  some 
remedies  which  have  been  followed  by  recovery ;  but 
I  should  employ  them  merely  as  desperate  remedies. 

The  passage  of  gall-stones  through  the  ducts  is 


ON   BILIOUS   DISEASES,    ETC.  803 

often  attended  with  severe  pain.  In  some  persons, 
pain  from  this  cause  occurs  frequently,  not  obstruct- 
ing the  passage  of  bile  every  time,  but  once  in  four 
or  five  times,  as  it  may  happen.  It  is  a  great  object 
to  give  relief  to  patients  suffering  in  this  way.  I 
have  seen  several  such  cases,  for  which  I  have  directed 
Slie  bicarbonate  of  soda  in  liberal  doses,  such  as  a 
drachm  twice  a  day.  So  far  as  I  have  known,  the 
disease  has  disappeared  in  every  instance,  after  con- 
tinuing the  use  of  this  medicine  for  several  months ; 
but  some  of  the  patients  have  lived  at  a  distance  from 
me,  and  I  may  not  have  been  rightly  informed 
respecting  them. 

In  connection  with  the  above,  I  have  a  remark  to 
make  with  respect  to  urinary  calculi.  Cases  of  this 
sort  usually  go  into  the  hands  of  surgeons,  and  my 
acquaintance  w^ith  them  has  not  been  extensive.  I 
had  understood  that  the  mulberry  calculus  (the 
oxalate  of  lime)  was  of  rare  occurrence.  Now,  it  has 
happened  to  me  to  have  had  five  cases  of  this  calculus 
within  three  years ;  three  of  these  within  the  last 
year.  In  each  case,  the  calculus  has  been  examined 
by  Dr.  John  Bacon,  on  whose  report  I  place  entire 
reliance.  I  mention  this  as  showing  that  the  mul- 
berry calculus  is  not  a  rare  occurrence  in  this  vicin- 
ity. 


304 


An  irritable  bladder  is  among  the  common  troubles 
of  old  men.  The  first  symptom,  which  attracts  atten- 
tion, in  most  instances,  is  a  frequent  micturition  in  the 
night-time.  Sometimes  this  does  not  occur  in  the 
day ;  and,  when  it  does,  it  is  not  so  inconvenient  as  in 
the  night.  This  is  attributed  in  many  instances  to  an 
enlargement  or  an  induration  of  the  prostrate  gland ; 
sometimes  in  the  middle  lobe  only.  When  it  is  so, 
the  disease  may  become  very  grave,  and  may  prove 
fatal.  But  in  a  very  large  proportion  of  the  cases  I 
have  seen,  the  results  have  not  been  of  a  serious 
character.  I  have  introduced  the  subject  principally 
to  say  this.  I  feel  assured  that  many  persons  have 
suiFered  a  good  deal  from  their  apprehensions  under 
this  malady,  and  accordingly  have  not  been  satisfied 
without  the  trial  of  troublesome,  if  not  very  powerful 
remedies.  To  one  affected  with  this  malady,  I  would 
say,  "  take  care  of  your  general  health,  keep  every- 
thing well  balanced,  do  not  make  yourself  weak  by 
confinement  within  doors,  and  do  not  fear  a  diet 
sufl&ciently  nutritious,  nor  too  readily  omit  the  use  of 
wine,  if  you  have  been  accustomed  to  it.  But  then 
I  would  add,  watch  the  effect  of  your  diet,  and  omit 
acids,  or  wine,  or  anything  else,  which,  on  careful 
observation,  appears  to  aggravate  your  disease.  Above 
all,  keep  your  bowels  regular.     Have  you  haemor- 


ON   BILIOUS  DISEASES,    ETC.  805 

rhoids  or  prolapsus  ani,  seek  relief  from  the  surgeon. 
If  diet  and  exercise  will  not  keep  the  bowels  regular, 
use  cold  Avater  injections ;  but  avoid  purgatives,  and 
certainly  harsh  ones."  These  remarks  in  regard  to 
the  state  of  the  bowels  are  founded  on  the  connection, 
which  I  have  found  to  exist,  between  the  rectum  and 
the  bladder  in  these  cases  ;  and  on  the  suspicion  that 
sometimes  the  trouble  in  the  bladder  has  originated 
in  disease  in  the  rectum. 

Here  is  a  short  letter,  but  you  may  think  it  long 
enough,  as  it  does  not  furnish  you  with  many  weapons 
for  the  relief  of  disease.  I  am  sensible  of  the  defi- 
ciency, yet  I  hope  the  letter  may  be  of  some  use  to 
you.  It  guards  you  against  following  popular  no- 
tions ;  and  may  induce  you  not  to  employ  violent 
remedies  till  you  are  assured  that  they  are  needed. 
20* 


LETTER  XVI, 

ON   BOILS. 

Boils  are  among  the  troubles  for  which  your  friends 
will  laugh  at  you,  rather  than  sympathize  with  you ; 
and  it  is  best  to  laugh,  too,  if  you  caT).  But  a  boil  is 
a  sore  trouble ;  proverbially  so.  It  C.ts  fallen  to  my 
lot  to  study  the  natural  history  of  boils  somewhat,  and 
to  study,  also,  the  treatment  of  them.  The  common 
accounts  of  them  are  too  superficial.  Dr.  Watson,  in 
his  lectures,  gives  the  most  correct  description  of  them 
which  I  remember  to  have  seen ;  but  it  is  brief,  and  I 
think  something  may  be  added  to  it  with  advantage. 

A  furuncle^  or  boil^  commences  in  the  form  of  a 
pimple.  It  is  a  hard  pimple,  though  very  small  at 
first ;  and  sometimes,  but  not  always,  it  is  the  seat  of 
a  stinging  pain  which  calls  attention  to  it.  When 
pressed  upon,  the  part  is  found  to  be  somewhat  sensi- 
tive. Within  two  or  three  days  this  becomes  a  pus- 
tule ;  or,  in  other  words,  a  little  pus  is  formed  on  its 
head,  the  pimple  enlarging.     A  soreness  comes  on,  and 


ON  BOILS.  807 

the  tenderness  increases ;  and  those,  who  watch  their 
sensations,  feel  as  if  something  was  piercing  slowly 
through  the  true  skin.  This  sensation  sometimes 
conveys  the  idea  of  a  caustic  eating  slowly  through 
the  cutis.  At  the  end  of  about  a  week  this  process,  in 
which  the  disease  is,  in  fact,  extending  through  the 
skin,  is  finished ;  and  then  the  swelling  begins  to  in- 
crease, as  if  from  something  placed  under  the  skin. 
We  may,  perhaps,  regard  the  primary  disease  as 
terminating  at  this  period.  There  is,  then,  something 
formed  under  the  skin  which  acts  like  a  foreign  sub- 
stance. I  take  it  that  this  something  is  fibrin,  or 
coagulable  lymph,  deposited  in  the  subjacent  cellular 
membrane.  I  am  not  sure  whether  this  is  all,  or 
whether  a  minute  portion  of  the  cellular  membrane  is 
involved,  and,  undergoing  a  species  of  gangrene,  con- 
stitutes, with  the  lymph,  the  foreign  substance.  It 
would  seem  that  what  follows  consists  in  the  effort  to 
separate  and  throw  out  this  slough,  or  foreign  matter. 
From  this  period,  early  in  the  second  week  of  the 
disease,  the  swelling  and  the  pain  increase.  The  ex- 
tent of  the  tumefaction  varies  in  its  diameter  from 
three  quarters  of  an  inch  to  two  inches.  In  some 
cases  an  erysipelatous  inflammation  is  added,  and  this 
spreads  over  a  space  equal  to  the  back  of  the  hand,  or 
f^ven  more.     The  part  thus  affected  puffs  up  more  or 


308  ON   BOILS. 

less,  but  this  swelling  usually  subsides  in  three  or  four 
days.  It  is  not  concerned  in  the  regular  process  of 
the  boil. 

In  the  first  week,  while  the  disease  is  extending 
through  the  cutis,  the  pustule  enlarges,  and  more  or 
less  matter  is  formed.  This  is  accompanied  by  a 
burning  pain,  which  the  inexperienced  attribute  to  the 
purulent  matter.  If  it  be  a  bad  boil,  the  patient 
thinks  he  has  already  suffered  enough,  and  punctures 
the  pustule,  with  a  sanguine  hope  of  relief  For  a 
short  time,  perhaps,  there  is  some  relief,  but  within 
two  days,  if  not  in  one,  he  finds  the  swelling  and  the 
pain  decidedly  augmented.  Then,  probably,  he  is 
charged  by  those  about  him  with  carelessness,  and 
with  having  taken  cold  in  the  boil ;  or,  perhaps,  it  is 
thought  that  he  has  used  the  wrong  salve,  or  the 
wrong  poultice.  It  is  thus  that  philosophical  nurses 
and  goodies  are  always  ready  to  explain  the  changes 
in  a  disease,  which  meantime  is  pursuing  its  own 
proper  routine.  The  suppuration  goes  on  beneath  the 
derma,  and  at  length  an  opening  takes  place,  so  that 
some  matter  is  discharged  from  the  depth  of  the  boil, 
and  this  matter  is  often  colored,  more  or  less,  by  blood ; 
but  the  end  is  not  yet.  On  the  other  hand,  it  is  then, 
ut  the  end  perhaps  of  the  second  week,  that  the  great 
soreness  is  first  noticed;  the  soreness  which  is  proverbial. 


ON  BOILS.  809 

There  is  not  any  other  disease,  known  to  so  large  a  pro- 
portion of  mankind,  in  which  the  soreness  is  so  great  as 
in  this ;  and  thence  the  common  phrase,  "  as  sore  as  a 
boil."  This  soreness  has  its  seat  in  the  inner  surface, 
by  which  the  core  or  slough  is  enclosed,  and  to  which 
it  is  attached.  Accordingly,  in  cases  where  the  parts 
open  so  as  to  expose  this  core  to  view,  if  you  touch  it, 
and,  still  more,  if  you  attempt  to  draw  it  out,  the 
patient  screams  with  the  pain.  It  is  like  tooth-draw- 
ing. When  the  opening  has  taken  place,  you  do  not 
find  a  cup,  but  rather  a  boggy  mass,  from  which  the 
pus  oozes  out.  In  the  course  of  the  third  week  there 
comes  a  period,  when  the  patient  feels  that  the  pain 
and  soreness  have  abated ;  matter  is  discharged  more 
freely,  and  the  swelling  is  evidently  diminishing.  In 
twenty-four  or  forty-eight  hours  from  this  period,  a 
little  ragged  wad  makes  its  exit  from  the  cavity ;  then 
the  parietes  come  together,  and,  in  another  day  or  two, 
the  trouble  seems  all  over.  When  the  core  has  been 
looked  for,  and  is  at  length  brought  out  to  sight,  some 
disappointment  is  often  experienced.  It  is  smaller 
than  was  expected,  even  when  it  is  in  its  most  perfect 
state.  The  truth  is,  that,  from  the  moment  it  is  de- 
tached from  the  living  parts  about  it,  the  core  shrinks ; 
and  that  is  the  time  when  the  tenderness  subsides. 
Besides,  it  happens  in  most  instances,  that  the  core  or 


810  ON  BOILS. 

elough  is  not  discharged  in  an  entire  state.  It  has 
been  decaying,  and  I  may  say  rotting,  before  its  sepa- 
ration ;  and,  when  detained  awhile  before  its  expulsion, 
it  separates  into  parts,  which  are  washed  out  with  the 
pus.  After  the  discharge  of  this  substance  is  quite 
completed,  there  is  not  much  more  suffering,  provided 
the  part  is  defended  from  injury ;  but  another  week 
passes  even  then  before  the  skin  is  quite  sound  and 
well,  so  as  to  bear  pressure  without  inconvenience. 
From  the  first  pimple  to  this  termination,  four,  and 
often  five,  weeks  are  occupied ;  but  the  really  painful 
period  is  one  or  two  weeks,  according  to  the  severity 
and  extent  of  the  boil.  For,  as  neither  all  men  nor 
all  oak-trees  are  of  the  same  size,  so  the  furuncle,  also, 
varies  in  its  magnitude. 

The  description  I  have  given  is  that  of  the  disease 
in  its  most  regular  and  most  usual  course.  But,  like 
its  betters,  the  boil  has  it^  varieties.  If  you  watch  an 
apple-tree  from  the  time  when  its  blossoms  have  fallen 
and  the  fruit  is  set,  you  find  this  fruit  falling  off  almost 
daily,  at  every  period  of  its.  growth,  varying  accord- 
ingly in  size,  and  often  imperfect  in  shape;  and,  at 
last,  when  you  come  to  the  gathering,  the  apples  differ 
in  shape,  as  well  as  in  size ;  for,  in  a  large  proportion 
of  them  one  half  is  more  perfectly  developed  than  the 
other.     So  it  is  with  boils  at  the  present  day ;  and,  I 


ON  BOILS.  811 

doubt  not,  if  there  had  been  some  close  observers 
attending  Job,  the  remarks  I  have  made  would  have 
been  written  down  in  his  book.  The  variety,  so  com- 
mon as  to  have  acquired  an  appropriate  epithet,  is  the 
blind  boil.  This  is  only  a  dwarf,  sometimes  ill-shaped, 
and  like  some  human  'dwarfs  it  may  have  a  sharp 
temper.  It  seems  to  me  that,  in  the  case  of  the  blind 
boil,  the  boring  through  the  cutis,  or  derma,  and 
forming  the  core,  which  I  have  described  as  the  first 
stage  of  the  disease,  is  not  perfected.  This  process 
stops  in  some  part  of  the  swollen  cutis,  and  the  core 
is  not  formed,  or  not  fully.  The  swelling  is  not  so 
large  as  in  the  perfect  boil ;  and  the  duration  of  the 
whole  disease  is  shortened.  As  this  stoppage  may 
take  place  at  any  point  in  the  cutis,  so  the  tumor  will 
vary  in  magnitude.  Moreover,  the  suppuration  is 
very  imperfect,  and  the  bleeding  is  large  in  proportion. 
The  other  varieties  are  marked  only  by  imperfections 
in  different  degrees,  as  happens  to  the  apples.  I  must 
except,  however,  one  variety,  in  which,  soon  after  the 
boil  opens,  a  fungus  rises,  circular  in  form,  with  a 
flat  head,  a  quarter  of  an  inch  or  more  above  the  sur- 
face of  the  skin.  No  core  is  seen.  The  fungus  is 
exquisitely  tender.  After  four  or  five  days  it  sinks 
down,  and  there  is  formed  a  much  larger  cicatrix  than 
in  other  cases.     It  seems  that  a  considerable  portion 


312  ON  BOILS. 

of  the  cutis  is  destroyed.  We  must  infer  that  there 
is  not  any  core  in  such  a  case,  but  that  some  injury  is 
done  to  the  parts  which  prevents  the  healing  for  a 
time,  just  as  happens  when  a  wound  in  the  flesh  will 
not  heal  because  there  is  a  piece  of  dead  bone  in  the 
bottom  of  it.  But  I  cannot  trace  over  the  whole  pro- 
cess in  accordance  with  this  view  of  the  case.  It  is  a 
hint  which  may  lead  some  one  to  a  discovery  of  the 
true  pathology  in  this  little  afiair. 

It  seldom  happens  that  one  boil  comes  alone.  More 
commonly  there  are  several  in  succession,  and  not 
rarely  a  dozen  or  twenty.  Some  persons  count  these 
successive  boils  by  hundreds.  These  will  be  recurring 
during  one,  two,  and  even  three  years.  It  is  not  un- 
common to  see  two,  and  sometimes  there  will  be  found 
four  or  five,  on  the  same  person  at  one  time ;  but  not 
all  of  the  same  age.  When  large  numbers  occur  in 
succession,  I  believe  it  will  be  found  that  many  of 
them  are  small. 

At  some  periods  boils  are  epidemic.  In  1852  and 
1853  they  were  very  common  in  this  country,  and  in 
Europe  also.  During  these  years  there  were  many 
persons,  who  could  boast  of  the  large  numbers  they  had 
endured. 

Happy  the  man  who  can  point  out  the  causes  of  the 
diseases  he  sees !     If  one  could  show  any  peculiar  state 


ON    BOILS.  313 

of  the  system  giving  rise  to  boils,  he  might,  perhaps, 
learn  how  to  prevent  them.  I  am  not  the  happy  man 
in  this  instance,  though  I  have  been  watching  persons 
affected  with  the  disease  for  very  many  years.  In 
each  individual  instance  you  will  find  ingenious  people 
around  the  patient,  who  can  explain  the  matter  quite 
to  their  own  satisfaction.  In  one  case  butter  and 
gravy,  and  other  articles  called  rich^  are  accused  as 
the  source  of  the  evil.  In  another  it  is  low  living 
which  is  suspected.  I  first  learned  that  many  boils 
occurred  in  succession  many  years  ago.  I  then  had 
two  patients,  one  of  whom  had  them  for  a  year,  the 
other  for  eighteen  months.  One  of  these  was  a  gen- 
tleman, then  young,  of  a  very  thin,  spare  habit,  with 
sharp  and  distinct  features,  a  dry  skin,  abstemious  in 
his  diet,  and  regular  in  his  whole  course  of  life.  The 
other  was  a  lady,  also  young,  above  common  size, 
plump,  rather  fat,  rotund,  with  a  soft  skin,  looking  as 
if  she  lived  on  fat  things.  Comparing  these  two  cases 
carefully,  I  could  not  find  anything  common  to  them ; 
but  the  contrary.  The  young  lady  was  living  at  her 
ease,  though  she  could  not  be  called  indolent.  The 
gentleman  was  one  of  our  active  merchants,  never  idle. 
I  have  been  equally  unfortunate  since  the  time  when 
I  saw  these  two  patients.  Others  have  differed  from 
each  other  as  much,  and  in  every  way.  They  have 
27 


S14  ON  BOILS. 

been  of  almost  all  ages,  all  temperaments,  all  habita 
as  to  diet,  etc. ;  some  perfectly  healthy  in  their  con- 
stitutions, others  far  otherwise.  Among  them  some 
have  been  tuberculous. 

The  subjects  of  boils  are  comforted  with  the  assur- 
ance that  they  are,  or  will  be,  the  better  for  them ;  or, 
at  least,  that  they  are  saved  by  them  from  internal 
diseases.  One  cannot  prove  that  assertions  like  these 
are  ill  founded.  I  Oan  only  say  that  I  have  looked 
carefully  and  honestly  for  evidence,  in  support  of 
them,  without  success.  A  valued  friend  of  mine,  a 
lady  between  forty  and  fifty  years  of  age,  has  raised 
blood,  more  or  less  freely,  from  her  fourteenth  year ; 
and  has  at  times  been  much  impaired  in  health  other- 
wise, though  always  exhibiting  a  great  power  of 
endurance,  with  the  aid  of  a  very  strong  mind.  Since 
she  was  forty  she  has  had  boils  for  two  or  three 
years.  During  those  years,  and  since,  she  has  suf- 
fered severely  from  the  same  complaints  as  before. 
This  has  not  happened  under  my  observation,  for  she 
was  living  at  a  distance  from  me,  but  I  have  the  facts 
on  good  authority. 

Though  I  cannot  point  out  the  peculiar  fault  in  the 
constitution,  or  habits  of  patients  who  have  boils,  I  can 
show  how  they  are  brought  on  in  some  cases.  Blis- 
ters produced  by  cantharides  will  commonly  heal  in  a 


ON  BOILS.  .815 

few  days,  if  the  cuticle  is  not  turned  off  from  them. 
But,  when  it  is,  they  often  take  on  a  new  inflamma- 
tion, for  a  time  will  not  heal,  and  become  sore  blisters. 
As  these  sore  blisters  are  healing  you  will,  not  unfre- 
quently,  find  them  surrounded  by  a  thick  crop  of 
pustules  of  various  sizes.  Watching  the  patient,  you 
may  find  these  pustules  followed  by  others  of  a  larger 
size,  much  fewer  in  number,  and  at  a  greater  distance 
from  the  blister.  Next,  at  a  still  greater  distance,  you 
will  find  a  boil,  and  then  another,  and  another.  In 
such  a  case  you  may  find  the  same  trouble  continuing 
for  many  months.  Where  poultices  have  been  applied 
to  boils  you  will  often  find  similar  pustules  on  the 
margin  of  the  circle  covered  by  the  poultice,  and  a 
new  crop  of  boils  extending  from  them.  Nearly  forty 
years  ago  I  made  an  issue  on  the  breast  of  a  consump- 
tive patient.  He  shortly  afterwards  went  to  Cuba. 
On  his  return  he  told  me  that  he  had  a  constant  suc- 
cession of  boils  during  his  absence.  They  began  near 
the  issue,  and  they  continued  to  show  themselves  for 
nine  months.  The  tuberculous  disease  went  on,  ap- 
parently undisturbed  by  the  disease  on  the  skin. 

It  is  well  known  that  patients,  whose  skins  become 
sodden  under  hydropathic  treatment,  are  very  often 
affected  by  boils;  at  first  numerous  and  small,  after- 
wards fewer  and  larger.     At  least  I  believe  that  they 


316  ON  BOILS. 

pursue  this  course,  juSt  as  happens  when  they  arise 
from  blisters;  only,  after  the  water  treatment,  as  I 
take  it,  the  boils  come  at  once  on  various  parts  of  the 
body,  instead  of  starting  from  a  central  point.  The 
cause  in  these  cases  is  much  the  same  as  exists  in  the 
the  poultices. 

Let  it  be  understood  that  many  persons  are  afflicted 
with  this  same  disease,  without  having  been  subjected 
to  any  of  the  causes  above  described. 

Having  been  thus  full  in  the  description  of  boils 
and  in  the  discussion  of  their  causes,  I  come  now  to 
the  treatment.  Is  anything  useful  to  be  done  to  the 
part  affected  ?  Can  anything  be  done  to  prevent  the 
recurrence  of  the  disease  ? 

As  to  the  first  question  I  reply,  unequivocally,  in 
the  affirmative.  The  boil  cannot  be  jugulated,  as  it 
has  no  neck ;  but  its  head  may  be  split  open  in  ita 
embryo  state,  and  there  will  be  an  end  of  it.  I 
endeavored  to  describe  the  disease  from  its  very  com- 
mencement on  this  account.  One  could  not  say  with 
entire  confidence,  on  examining  a  pimple,  that  it 
would,  or  would  not,  become  a  boil.  It  has  not 
certain  and  specific  characters.  But  if  a  man  has 
had  one  boil,  and  soon  after  has  a  pimple,  such  as  I 
have  described,  the  probability  is  that  this  will  grow 
into  another  boil.     If  he  has  had  two  or  three  boils 


ON  BOILS.  817 

about  his  hand  and  arm,  and  a  pimple  comes  in  the 
same  region,  it  is  almost  certain  that  that  will  grow 
into  a  boil.  Now,  what  I  have  to  say  is,  that  if  you 
carry  the  point  of  a  lancet  through  the  middle  of  that 
pimple  it  will  dwindle  away.  The  sooner  this  is  done, 
after  the  pimple  is  formed,  the  better.  The  treatment 
succeeds  if  adopted  on  the  second  or  third  day ;  and 
even  later  it  does  some  good.  If  done  late  the  disease 
is  not  entirely  overcome ;  it  is  blighted  and  is  short- 
lived. This  treatment  is  not  worth  trying  after  the 
fifth  or  sixth  day  ;  not  after  the  affection  has  extended 
deep  into  the  true  skin.  You  will  sometimes  see, 
when  the  pustule  has  just  formed,  if  the  cut  does  not 
cross  exactly  in  the  centre,  that  a  half,  one-sided 
pustule  will  be  formed,  yet  the  disease  will  not  come 
to  much.  Be  it  noted,  however,  that  this  operation 
will  not  succeed,  if  it  be  not  performed  thoroughly 
and  exactly.  The  lancet  should  be  plunged  through 
the  cutis,  beginning  just  outside  of  the  pimple,  and 
be  carried  through  this  pimple,  at  the  same  depth, 
dividing  it  as  near  as  may  be  into  two  equal  parts. 

The  difficulty  in  the  treatment  is  to  discover  the 
pimple  on  its  first  formation.  Occasionally  it  will 
come  in  a  quarter,  which  the  patient  has  not  thought 
of,  and  often  where  he  cannot  see  it.  But  usually 
the  pimples  come  in  the  vicinity  of  the  previous  boils, 
27=* 


318  ON  BOILS. 

as  on  the  head,  on  one  of  the  limbs,  or  on  the  parta 
around  the  pelvis.  If  the  patient  is  apprised  where 
the  pimple  will  probably  come,  he  may,  by  feeling 
round  the  suspected  region,  be  sure  to  discover  it  at 
its  first  coming.  For  this  purpose  let  him  examine 
himself  twice  a  day.  He  may  fancy  that  there  are 
pimples  where  there  are  not,  but  the  physician  will 
decide  that  matter ;  or,  if  both  should  be  in  error,  it 
is  not  a  great  evil  to  feel  the  lancet  three  times,  if  one 
boil  can  be  saved  by  it. 

Let  me  give  one  example.  A  gentleman,  about 
seventy-five  years  of  age,  called  me  to  see  a  boil  formed 
on  the  hairy  scalp,  near  his  ear.  It  was  not  of  the 
largest  size,  but  it  proved  a  sore  trouble  to  him. 
Nothing  had  occurred  to  explain  the  occurrence  of  it 
Before  this  was  well,  he  sent  for  me  to  see  another, 
much  smaller,  in  the  same  vicinity,  which  had  been 
coming  four  or  five  days.  I  divided  this  freely,  and 
with  as  much  success  as  I  had  promised  him.  The 
disease  went  on,  but  the  boil  was  much  smaller  than 
the  first.  He  now  realized  the  importance  of  watch- 
ing for  the  pimples,  and  he  had  six  in  rapid  succession, 
all  under  the  hair.  I  divided  each  one,  and  arrested 
the  disease  in  each  case.  I  began  the  use  of  the 
sulphate  of  quinia  as  soon  as  the  third  boil  commenced, 
which  was  the  first  I  saw  in  the  state  of  a  pimple.    It 


UN    BOILS.  319 

required  some  days  before  I  arrived  at  a  sufficient  dose 
of  this  medicine  to  affect  the  system  ;  the  patient  being 
an  old  man,  I  had  been  very  cautious  in  the  use  of 
it.  From  the  time  the  constitutional  effect  of  it 
appeared  the  pimples  ceased  to  show  themselves. 

In  this  case  we  have  an  instance  of  the  tendency  to 
a  recurrence  of  boils  ;  of  their  tendency  to  keep  in  one 
neighborhood,  which  is  not  always  but  often  shown ; 
of  the  effects  of  an  early  division  of  the  pimples  ;  and 
of  the  effects  of  the  quinia,  which  I  shall  treat  of 
presently. 

Now,  as  to  the  second  question  ;  when  a  patient  has 
had  several  boils  can  anything  prevent  their  further 
recurrence  ?  To  this  I  cannot  give  so  confident  an 
answer  as  to  the  first  question  ;  but  I  think  it  may  be 
done  in  a  large  proportion  of  instances.  If  a  man 
has  had  ten  boils  in  succession,  you  cannot  be  sure 
that  he  will  have  one  more.  If,  then,  you  administer 
your  medicine,  and  he  has  no  more  for  a  year,  you 
cannot  be  sure  that  the  medicine  has  produced  the 
exemption.  But  if  you  use  the  same  medicine  for  a 
number  of  persons,  of  whom  some  have  had  three 
boils,  some  ten,  and  so  on  to  a  hundred,  and  if  in  the 
largest  number  of  these  persons  the  disease  does  not 
recur,  you  then  have  a  right  to  believe  that  the  disease 
was  arrested  by  the  medicine.     Now,  this  is  what  has 


320  ON   BOILS. 

happened  in  my  practice.  For  twenty  or  more  years 
I  have  given  the  sulphate  of  quinia  with  the  result 
above  described. 

In  observing  the  effects  of  this  medicine  in  intermit- 
tent fever  and  intermittent  headache,  it  appeared  to 
me  certain  that  it  did  not  produce  its  beneficial  effects 
by  acting  as  a  tonic.  In  those  diseases  the  paroxysms 
cease  without  any  evidence  of  increase  in  strength,  as 
measured  by  observation  of  any  of  the  functions, 
organic,  or  animal.  In  what  way,  then,  does  the 
cinchona,  or  do  the  other  remedies,  operate  ?  It  has 
seemed  to  me  that  they  operate  by  taking  away,  or 
overcoming,  the  susceptibility  to  the  disease.  This  at 
first  was  only  an  hypothesis.  It  was,  however,  suffi- 
ciently plausible  to  lead  me  to  bring  it  to  the  test  of 
experiment.  Not  to  make  a  long  story,  I  will  say  at 
once  that  I  have  given  the  sulphate  of  quinia,  the 
most  convenient  preparation  of  cinchona,  for  many 
years,  on  this  principle,  in  various  diseases  ;  that  is,  in 
cases  of  boils,  of  styes  upon  the  eyelids,  and  of  some 
eruptions  which  have  kept  recurring  in  different  parts 
of  the  body,  though  not  severe  in  their  character,  and 
in  various  painful  affections.  Of  the  effect  in  these  last 
I  treated  in  another  letter.  The  result  has  been  very 
satisfactory.  I  do  not  say  that  success  has  always 
followed   this  treatment.     It  certainly  has  not;  but 


ON  BOILS.  82t 

the  results  have  been  satisfactory  in  so  largo  a  propor- 
tion of  instances,  as  not  only  to  justify  the  practice, 
but  to  make  me  regard  it  as  my  duty  to  pursue  it  and 
to  point  it  out  to  others.  I  have  the  less  hesitation  in 
saying  this,  inasmuch  as  the  treatment  is  not  of  a  kind 
likely  to  be  injurious. 

In  stating  my  opinions  on  this  subject  I  am  not 
anxious  to  make  any  claims  to  originality.  The  hon- 
est truth  is,  that  I  cannot  tell  whether  I  got  the  first 
hints  from  any  one  else,  or  not.  It  is  the  truth  I 
have  cared  for,  in  this  and  other  cases,  and  this  I  wish 
to  present  to  others ;  and  not  a  statement  of  the  rela- 
tive claims  of  those,  who  may  have  been  thought  the 
original  discoverers.  A  day  or  two  before  I  began  to 
write  this  letter,  after  looking  into  various  works  in 
respect  to  boils,  I  took  up  the  excellent,  and  well- 
known  lectures,  by  Dr.  Watson,  of  London.  I  had 
not  any  recollection  of  a  mention  of  this  disease  by 
him,  but  I  found  a  brief,  and,  as  far  as  it  went,  a  cor- 
rect statement  on  the  subject.  I  was  surprised  to  find 
that  he  noticed,  what  I  had  not  found  done  by  any 
one  else,  the  commencement  of  a  boil  in  "  a  tender 
knot,  just  beneath  the  surface,"  which  I  regard  rather 
as  a  pimple;  also,  that  he  mentioned,  as  practised 
by  some  persons,  cutting  "  the  hard  tumor  through 
while  it  is  yet  crude,"  and  the  use  of  the  sulphate  of 


322  ON   BOILS. 

quinia  in  certain  cases ;  but  this  as  a  tonic,  and  not 
probably  in  the  full  doses  which  I  deem  necessary. 
My  practice,  however,  was  not  derived  from  Dr.  Wat- 
son. I  could  mention  various  things,  for  which  I  am 
indebted  to  this  learned  and  sagacious  professor,  but 
the  treatment  of  the  disease  under  consideration  is  not 
one  of  them.  His  work  was  published  in  1845,  and 
did  not  reach  me  till  a  year  later,  while  the  treatment, 
which  I  have  described,  was  adopted  ten  or  twelve 
years  before  that  date. 

It  is  well,  perhaps,  for  me  to  state,  distinctly,  the 
extent  to  which  I  use  the  sulphate  of  quinia.  In  the 
case  of  an  adult,  I  give  from  twelve  to  sixteen  grains 
of  that  article,  divided  into  three  or  four  doses,  on  the 
first  day ;  and  if  the  peculiar  effects  of  the  medicine 
on  the  head  or  ears  do  not  take  place,  I  increase  the 
quantity,  the  next  day,  by  four  grains ;  and  continue 
to  increase  the  quantity  daily  by  four  grains,  until 
there  is  some  evidence  that  the  patient  has  got  as 
much  as  he  can  comfortably  bear.  On  the  day  after 
some  inconvenience  is  occasioned  by  the  medicine,  I 
lessen  the  daily  allowance  by  four  grains.  If  this  is 
borne  well,  or  whatever  daily  allowance  is  borne  with 
ease,  I  continue  the  same  for  four  or  five  days,  and 
then  gradually  bring  the  quantity  down  to  two  grains 
in  a  day.     I  prefer  not  to  omit  the  medicine  entirely 


ON   BOILS.  328 

for  three  or  four  weeks.  1  state  here  the  course  which 
I  deem  necessary  to  secure  all  the  good  effects,  which 
the  medicine  can  afford ;  but  I  will  add  that  I  have 
reason  to  believe  a  shorter  course  of  the  medicine  will 
often  suffice.  Some  persons  have  been  too  impatient 
to  do  all  I  now  advise,  and  have  done  well.  Others, 
however,  have  been  obliged  to  go  back  and  begin  the 
treatment  over  again.  What  I  deem  essential  is  to 
begin  with  large  doseS;  so  as  to  make  a  distinct  im- 
pression on  the  system  as  early  as  possible.  This 
having  been  done,  smaller  doses  afterwards  will  main- 
tain this  good  impression.  Though  we  have  no  inter- 
mittent fevers  in  our  region,  except  casually,  I  believe 
that  the  same  principles  should  govern  the  use  of  the 
quinia  in  that  disease.  It  is  very  probable  that 
arsenic  might  produce  all  the  good  effects  which 
the  quinia  does,  in  cases  of  boils,  but  I  have  never 
tried  it. 

I  must  say  a  few  words  on  the  local  treatment  of 
boils.  And,  first  of  all,  do  not  apply  poultices  to 
them.  It  is  enough  that  they  may  occasion  an  in- 
crease of  the  disease.  At  particular  times  they  are 
thought  to  be  comfortable ;  but,  on  the  whole,  I  regard 
them  as  dirty  and  troublesome  applications,  and  as 
often  causing  much  discomfort  to  the  patient.  They 
are  endured  under  the  popular  notion  that  they  are 


324  ON   BOILS. 

necessary  to  bring  the  boil  to  its  proper  end ;  that 
they  draw  to  the  surface  the  noxious  humors.  I 
always  pay  so  much  respect  to  popular  notions  as  to 
bring  them  to  the  test  of  experience,  if  I  do  not  see 
any  certain  objection  to  so  doing.  I  did  this  long  ago 
as  to  poultices  for  boils,  and  I  became  satisfied  that 
there  was  an  error  on  this  subject.  Occasionally,  for 
a  few  hours,  a  warm  and  moist  application  is  soothing. 
For  that  purpose  a  fomentation  with  warm  water  may 
be  directed.  A  better  thing,  however,  where  it  can 
be  had,  is  a  piece  of  spongio-piline^  wet  in  warm 
water.  This  may  be  wet  with  ease  at  any  moment, 
and  is  free  from  some  of  the  evils  of  a  common  poul- 
tice. But  much  soaking  of  any  kind  is  bad.  For  the 
rest,  the  simplest  applications  are  the  best.  The 
spermaceti  cerate,  or  something  like  it,  is  sufficient  to 
protect  the  diseased  part  from  irritation,  and  that  is 
all  which  is  needed.  A  piece  of  linen,  or  lint,  spread 
"with  the  cerate  may  be  kept  in  its  place  by  very  nar- 
row strips  of  adhesive  plaster.  Until  some  discharge 
has  taken  place  one  dressing  will  last  for  two  or  three 
days ;  afterwards,  the  dressing  should  be  renewed  as 
often  as  cleanliness  requires.  Let  me  add  one  more 
direction  to  be  observed,  at  least  as  long  as  the 
soreness  of  the  part  continues,  and  this  I  shall  add 


ON   BOILS.  825 

in  words  which  I  read  more  than  fiftj  years  ago,  and 

have  never  forgotten,  written  I  believe  by  Mr.  Sharpe, 

of  Guy's  Hospital,  namely,   "  Do  not  cleanse  the  sore 

too  curiously." 

^        28 


LETTER  XVII. 

ON  THE  TREATMENT  OF  TYPHOID  FEVER. 

This  letter  shall  be  devoted  to  the  treatment  of 
typhoid  fever.  I  need  not  describe  the  disease.  You 
already  know  it  as  the  continued  fever  seen  every- 
where in  New  England,  and  to  be  found,  probably,  in 
every  part  of  the  world.  In  our  seaports  we  have  had 
the  yellow  fever,  occasionally,  within  the  last  sixty 
years,  if  not  before.  In  my  day,  the  spotted  fever, 
so  called,  prevailed  for  several  years  in  different  parts 
of  New  England.  The  typhus  fever,  as  understood 
at  the  present  day,  has  occasionally  been  seen  among 
us;  but,  probably,  always  imported  from  abroad. 
But  the  continued  fever,  called  typhoid,  is  the  disease 
which  is  never  absent  from  us,  and  which,  in  some 
seasons,  prevails  extensively,  now  in  one  place  and 
now  in  another. 

It  is  the  treatment  of  this  disease  I  wish  to  discuss. 
Can  this  disease  be  shortened  in  its  duration,  or  dimin- 
ished in  its  violence,  or  its  danger  to  life  lessened,  by 


ON  THE  TREATMENT  OF  TYPHOID  FEVER.  32T 

treatment  ?  These  are  interesting  questions,  and  it  is 
worth  some  trouble  to  ascertain  the  true  answers  to 
them.  Every  year  many  persons  suffer  from  this 
disease,  and  some  very  severely ;  many  die,  and  that 
at  an  early  period  of  life,  when  just  entering  on  its 
active  duties ;  and,  of  those  who  survive,  many  have 
their  vigor  lessened  and  their  comfort  and  usefulness 
abridged  for  months,  and  even  for  years,  after  the 
disease  has  left  them.  Can  these  evils  be  dimin- 
ished ? 

I  believe  that  the  opinion  has  been  gaining  ground 
among  us,  for  twenty  or  thirty  years  past,  that  the 
above  questions  must  be  answered  in  the  negative. 
Or,  if  it  is  thought  that  any  benefit  can  be  derived 
from  treatment,  it  is  maintained  that  this  is  of  very 
small  amount.  This  view  of  the  subject  is  favored  by 
my  friend  Dr.  Bigelow,  in  his  admirable  "  Discourse 
on  Self-limited  Diseases." 

There  is  a  great  presumption  in  my  mind  that  any 
opinion  advanced  by  Dr.  Bigelow  is  well  founded.  In 
this  community  his  decisions  have  a  most  deserved 
weight  and  influence;  and  most  especially  among 
those  who  are  the  most  competent  judges.  It  gives 
me  great  pleasure  to  bear  testimony  in  public,  as  I 
have  often  done  in  private,  to  his  high  claims  to 
respect  as  a  scholar  and  philosopher.     The  discourse 


828  ON  THE  TREATMENT  OF  TYPHOID  FEVER. 

to  which  I  have  referred  is  full  of  wisdom.  I  could 
say  more,  but  I  will  restrain  myself  from  a  fear 
that  we  may  be  thought  to  be  bandying  compli- 
ments. 

In  the  discourse  on  self-limited  diseases  Dr.  Bige- 
low  says,  as  follows : 

''  Before  quitting  the  subject,  I  beg  leave  to  intro- 
duce the  opinion  of  one  or  two  medical  writers,  in 
regard  to  the  possibility  of  interrupting  or  breaking 
up  this  disease  by  means  of  art.  M.  Louis,  of  whose 
researches  in  regard  to  typhoid  fever,  it  is  but  small 
praise  to  say  that  they  are  more  exact  and  comprehen- 
sive than  those  of  any  living  writer,  is  of  opinion  that 
the  disease  cannot  be  thus  intercepted.  '  Experience,' 
says  he,  '  has  shown  that  a  well-marked  typhoid  affec- 
tion is  not  capable  of  being  broken  up.'  To  this  tes- 
timony of  one  of  the  most  eminent  teachers  in  the 
French  metropolis,  it  may  net  be  amiss  to  add  that  of 
an  American  physician,  whose  opportunities  for  observ- 
ing the  disease  in  different  parts  of  New  England  were 
extensive,  and  whose  Essay  on  Typhus  Eever  well 
merits  an  attentive  perusal.  The  late  Dr.  Nathan 
Smith,  in  the  course  of  some  remarks  on  the  possibility 
of  interrupting  this  disease  at  its  commencement,  ob- 
serves: '  During  the  whole  of  my  practice  I  have  never 


ON  THE  TREATMENT  OF  TYPHOID  FEVER.  329 

been  satisfied  that  I  have  cut  short  a  single  case  of 
typhus,  that  I  knew  to  be  such.'  * 

"  Having  said  thus  much,  I  leave  the  subject  of  the 
tractabilitj  of  typhus  and  typhoid  fever  to  the  light 
of  future  investigation.  It  is  but  justice  to  state,  that 
numerous  and  highly  respectable  authorities  are 
declared  in  favor  of  the  efiicacy  of  art  in  shortening 
and  mitigating  these  diseases ;  and  it  will  be  a  source 
of  gratification  to  the  friends  of  humanity  and  science, 
should  it  ultimately  be  settled  that  the  active  treat- 
ment now  usually  pursued  at  the  commencement  of 
cases,  is  instrumental  in  lessening  their  duration, 
severity,  or  danger." 

It  will  be  seen  that  my  friend  is  an  unwillmg 
doubter ;  and  no  one  would  be  more  pleased  than  he, 
if  it  can  be  shown  that  any  check  can  be  given  to  this 
direful  disease,  and  that  the  questions  I  have  pro- 
pounded can  be  answered  in  the  afiirmative.  I  am 
not  prepared  to  assert,  positively,  that  they  can.be  so 
answered.  But  I  believe  that  I  can  bring  so  much 
evidence  on  that  side  of  the  question,  as  to  justify  the 

*  At  the  time  of  the  publication  alluded  to,  the  distinction 
between  typhus  and  typhoid  fevers  had  not  been  well  made  out. 
The  distinction  is  good,  though  writers  of  authority  differ  on  th« 
subject. 

28* 


330  ON  THE  TREATMENT  OF  TYPHOID  FE7EK 

trial  of  active  remedies  under  proper  circumstances ; 
naj,  so  much,  as  to  make  it  our  duty  to  trj  them 
until  further  evidence  shall  show  that  there  is  some 
fallacy  as  to  that  which  I  shall  adduce. 

It  is  from  my  report  on  typhoid  fever  in  the  Massa- 
chusetts General  Hospital,  made  in  1838,  that  I  shall 
derive  the  evidence  referred  to. 

Without  going  into  all  the  particulars,  I  will  take 
what  relates  to  the  effects  of  emetics.  This  report 
was  grounded  on  the  cases  of  that  disease  in  the 
hospital  from  1822  to  1835,  inclusive.  From  this  it 
appears  (pp.  7  and  8)  that  on  a  fair  estimate  there 
was  one  death  in  about  eight  cases. 

Among  those  admitted  to  the  hospital 
in  the  first  two  weeks  of  the  disease,  one 
hundred  and  fifty  took  emetics  before  or 
after  admission  ;  of  these  one  hundred  and 
fifty,  thirteen  died,  being  1  in  11.53 

In  the  same  period  eighty  were  admit- 
ted who  did  not  take  emetics  ;  of  these  ten 
died,  being  1  in  8.00 

The  difference  is  very  striking.  But  of  the  one 
hundred  and  fifty  )vho  took  emetics,  some  took  them 
earlier  and  some  later  in  the  disease.  It  has  been 
thought  that  the  earlier  this  and  other  active  and 
depletory  remedies  are  administered,  the  greater  the 


ON  THE  TREATMENT  OF  TYPHOID  FEVER.  331 

benefit.     See  how  far  this  is  confirmed  by  the  same 
report. 

Fifty-nine  entered  the  first  week  of  the 
disease,  and  took  emetics  in  that  week  \ 
four  of  these  died,  being  1  in  14.75 

Thirty -one  entered  the  same  week,  and 
did  not  take  emetics  ;  of  these  three  died, 
being  1  in  10.33 

Ninety-one  entered  the  second  week, 
and  took  emetics  either  before  or  after 
admission  ;  of  these  nine  died,  being  1  in  10.11 

Forty-eight  entered  the  same  week, 
and  did  not  take  emetics  ;  of  these  seven 
died,  being  1  in  6.85 

The  advantage  was  on  the  side  of  those,  who  took 
emetics ;  but  more  decided  as  to  those  who  entered  the 
first  week,  than  as  to  those  who  entered  the  second.  The 
last  had  not  probably  been  so  well  nursed  in  the  first 
week  as  the  others.  But  also  they  had  not  on  an 
average  taken  the  emetic  so  early ;  and  that,  no  doubt, 
made  a  difference  in  favor  of  those  entering  the  first 
week.  My  own  experience  taught  me  long  ago  that 
emetics  were  most  useful  when  taken  within  the  first 
three  days  of  the  disease.  This  is  confirmed  by  the 
hospital  cases.  It  appears  from  the  report  that  thirty- 
two    patients    took    emetics  within    the  first    three 


332  ON  THE  TREATMENT  OF  TYPHOID  FEVER. 

days   of   the   disease ;    of    these   one   died,   1  in  32 
Twentj-seven  took  emetics  within  the  last  four 
days  of  the  first  week ;  of  these  three  died, 
being  1  in  9 

Undoubtedly  these  last  numbers,  relative  to  those 
who  took  emetics  in  the  last  four  days  of  the  first  week, 
are  less  favorable  than  would  be  found  if  the  number 
was  larger ;  for  the  proportion  of  deaths  is  greater  than 
in  those  who  entered  the  second  week,  and  took  emetics, 
and  of  whom  the  larger  part,  no  doubt,  took  their 
emetics  at  a  later  period  of  the  disease  than  the  above 
twenty-seven. 

If,  now,  we  inquire  what  was  the  efiect  on  the 
duration  of  the  disease  in  those,  who  took  emetics  and 
recovered,  it  does  not  seem  to  have  been  much  if  any- 
thing to  the  advantage  of  those  taking  emetics  later 
than  the  third  day.  But  as  to  those  who  took  emetics 
on  either  of  the  first  three  days  the  benefit  is  unequiv- 
ocal. 

Of  those  who  took  emetics  on  the  first  day  of 
the  disease,  the  average  day  of  convalescence 
was  the  14.66 

Of  those  who  took  emetics  on  the  second  day, 
the  average  day  of  convalescence  was  the  15.32 

Of  those  who  took  emetics  on  the  third  day, 
the  average  day  of  convalescence  was  the  16.46 


ON  THE  TREATMENT  OF  TYPHOID  FEVER.  333 

"While  of  those  who  took  emetics  on  the  fourth, 
fifth  and  sixth  days  of  the  disease,  and  recov- 
ered, the  average  day  of  convalescence  was 
the  19.45 

It  cannot  surely  be  attributed  to  accident  that  these 
results  were  so  favorable  to  those,  who  took  emetics, 
among  cases  not  selected  but  taken  as  they  came, 
through  many  successive  years.  But  I  feel  assured 
that  the  result  would  have  been  found  much  more 
favorable  had  all  those,  who  took  emetics  at  an  early 
period,  been  properly  managed  afterwards.  To  the 
best  success  of  this  mode  of  treatment  it  is  necessary 
that  great  care  should  be  taken  after  the  first  relief 
from  the  emetic.  However  well  the  patient  may  seem, 
he  should  be  treated  as  a  sick  man.  The  emetic 
should  be  followed  by  an  active  cathartic  on  the  fol- 
lowing day,  unless  it  should  itself  have  had  a  powerful 
operation  on  the  bowels.  Probably  this  was  done  in 
most  of  the  cases.  And  then,  for  a  week  at  least, 
however  well  the  patient  may  appear,  he  should  be 
restrained  from  all  efibrts  of  body  or  mind,  and  should 
be  kept  on  a  very  moderate,  bland  vegetable  diet. 
Though  the  headache  and  pain  in  the  back  and  limbs 
be  removed,  the  pulse  restored  to  a  natural  frequency, 
the  chills  and  heat  subsided,  still  the  liability  to  the 
disease  remains.      Therefore    the    disease  is  easily 


334  ON  THE  TREATMENT  OF  TYPHOID  FEVER. 

lighted  up  anew ;  and,  if  great  errors  are  committed, 
it  maj  return  in  its  full  force,  and  run  through  its 
entire  period.  All  this  I  have  learnt,  long  ago,  in 
private  practice.  Now,  when  we  consider  the  situa- 
tion of  patients  who  resort  to  a  hospital,  and  that  they 
would  not  go  there  if  they  had  the  comforts  of  good 
homes  and  careful  attendance,  it  will  be  seen  that  few 
of  them  will  get  the  full  advantage,  which  an  active 
treatment  at  the  onset  of  the  disease  might  have 
afforded  them.  I  am  in  truth  surprised  that  so  large 
a  proportion  of  those,  to  whom  my  report  refers,  did 
derive  such  marked  benefit  from  this  treatment.  Such 
would  not  commonly  be  the  result  in  hospital  practice 
of  large  cities.  I  think  it  may  be  explained  in  part 
by  the  recollection  that,  in  our  hospital  in  its  early 
years,  the  great  majority  of  the  patients  were  of  our 
native  stock,  and  bred  up  with  some  regard  to  the 
rules  of  prudence. 

In  reading  accounts  of  successful  practice  from  a 
medical  man,  however  honest  we  may  think  him,  it  is 
necessary  to  guard  against  the  disposition  on  the  part 
of  the  reporter  to  see  the  results  in  a  favorable  light. 
If  the  result  is  not  in  every  case  all  he  could  wish,  he 
is  prone  to  charge  the  patient  with  some  commission,  or 
omission,  which  may  explain  the  failure.  The  sugges- 
tions in  the  last  paragraph  are  not  however  to  be  looked 


ON  THE  TREATMENT  OF  TYPHOID  FEVER.  335 

at  in  this  light.  I  do  not  say  that  the  patients  re- 
ferred to  were  very  imprudent.  I  say  that  I  wonder 
that  there  was  so  much  prudence  among  them,  as  the 
good  results  give  evidence  of.  I  must  beg.  also,  to  call 
to  mind  some  circumstances  respecting  these  cases. 
The  patients  were  not  treated  by  me  from  the  begin- 
ning. The  number  was  small  for  whom  I  prescribed 
the  emetics.  I  did  not  plant  the  trees,  and  feel  a 
paternal  solicitude  in  watering  them.  A  very  large 
proportion  of  these  patients  had  their  emetics  before 
they  entered  the  hospital ;  probably  some  days  before. 
Nor,  when  they  got  there,  did  they  all  come  under 
my  care  ;  a  good  part  of  them  were  under  the  care  of 
my  colleagues.  Those  acquainted  with  our  hospital 
know  that  the  case  of  ev6ry  medical  patient  is  taken 
down  on  the  day  of  his  entrance  by  the  house  physi- 
cian. He  then  notes  the  remedies  employed  before 
the  admission  of  the  patient.  The  attending  physician 
dictates  daily,  if  the  case  be  an  acute  one,  the  state 
of  the  patient  and  the  treatment  to  be  pursued.  This 
is  all  placed  in  the  case-book  within  twenty-four 
hours.  There  is  no  chance  for  interpolation  at  a 
subsequent  period.  The  attending  physician,  in  going 
his  rounds,  cannot  be  supposed  to  bear  in  mind  every 
typhoid  patient,  whose  treatment  began  with  an 
emetic,  and  to  make  his  reports  more  favorable  accord- 


ON  THE  TREATMENT  OF  TYPHOID  FEVER 

ingly.  Still  less  can  it  be  suspected  that  the  case- 
book :  would  be  falsified  in  any  instance,  in  order  to 
make  a  favorite  remedy  appear  to  more  advantage. 

See,  now,  how  the  statements  in  my  report  on  ty- 
phoid fever  were  obtained  frpm  the  hospital  books.  I 
made  out  large  blank  tables,  having  columns  for  every 
important  symptom  and  for  the  remedies  employed ; 
distinguishing  those  administered  before  and  those 
after  the  entrance  into  the  hospital.  Then  taking  the 
hospital  books  in  their  order,  from  the  beginning,  I 
entered  the  name  of  each  patient  in  my  tables,  and 
the  entries  relative  to  him  in  the  corresponding 
columns.  The  particular^  had  to  be  sought  out 
patiently,  for  the  records  had  not  been  made  with 
reference  to  such  a  use  of  them.  To  go  through  three 
hundred  cases  in  this  way  was  the  labor  of  my  spare 
hours  for  several  months.  It  was  not  until  the  work 
was  finished  that  I  went  over  the  cases  to  obtain  the 
results  as  to  the  symptoms  of  the  disease,  its  treat- 
ment, and  its  favorable  or  unfavorable  termination. 
These  results,  then,  were  as  faithfully  represented  as 
could  by  any  means  be  done.  More  especially 
whether  death  occurred  more  or  less  frequently  under 
one  mode  of  treatment  than  under  another,  was 
ascertained  so  certainly,  as  to  preclude  all  chance  of 
error. 


ON  THE  TREATMENT  OF  TYPHOID  FEVER.  337 

Is  it  asked  if  those  patients  who  took  emetics  did 
not  before,  or  afterwards,  employ  other  remedies  ?  I 
reply,  that  they  did,  probably  in  every  instance.  Then, 
I  may  be  told,  that  I  might  be  misled  in  attributing 
the  favorable  results  to  the  emetics.  I  answer  thai 
the  other  remedies  employed  were,  no  doubt,  the  samo 
as  for  those  who  did  not  take  emetics.  I  say,  no  doubt ^ 
because  all  were  treated  by  the  same  physicians ;  and 
that  in  their  treatment  the  physicians  were  guided  by 
the  same  general  principles  in  one  set  of  cases  as  in 
the  other.  I  should  hope  that  a  benefit  was  obtained 
from  this  after  treatment ;  but  this  would  not  show 
that  the  difference  between  the  two  classes  of  cases 
was  not  to  be  attributed  to  the  only  difference  in  their 
treatment,  namely,  that  emetics  were  given  to  one 
class,  and  not  to  the  other.  If,  lastly,  it  be  asked, 
why  emetics  were  not  administered  to  all  the  typhoid 
patients,  I  reply,  that  many  of  them  were  admitted  at 
too  late  a  period  to  do  this  with  advantage  at  the  hos- 
pital: why  they  were  not  administered  before  the 
admission  of  the  patients,  must  be  answered  by  those 
who  had  the  care  of  them.  I  presume,  however,  that 
most  of  these  did  not  get  medical  advice  early ;  and 
that,  in  some  cases,  the  physicians  aid  not  think  well 
^f  the  practice,  or  found  some  objections  in  the  cir- 
cumstances of  the  particular  patients  under  their  care. 
29 


ON  THE  TEEATMENT  OF  TYPHOID  FEVER. 

There  are  other  remedieSj  besides  emetics,  for  the 
utility  of  ■vvhich  mj  report  affords  some  evidence ;  of 
which,  cathartics  at  the  commencement  of  the  disease, 
and  antimonials  in  doses  not  sufficient  to  induce  nau- 
sea, or  vomiting,  are  the  principal.  On  these  points 
I  must  refer  to  the  report  in  the  Transactions  of  the 
Massachusetts  Medical  Society. 

I  am  aware  that  one  doubt  may  lurk  in  the  minds 
of  some  of  my  brethren.  That  is,  whether  there  was 
not  some  error  as  to  the  disease  in  those  patients^ 
who  were  vomited  early,  and  in  whom  the  results 
were  favorable.  I  say  there  is  not  any  reasonable 
ground  for  such  distrust.  In  examining  the  cases  in 
the  hospital  books,  which  had  been  called  typhoid 
fever,  I  threw  out  all  which  were  doubtful,  as  is  stated 
in  the  report.  But  did  we  know  how  to  diagnosticate 
the  disease?  One  answer  to  this  is,  that  in  every 
fatal  case,  which  we  had  denominated  typhoid  fever, 
and  in  which  the  small  intestines  were  examined 
properly,  the  disease  in  Peyer's  glands  was  discovered. 
Another  answer  is,  that  a  very  large  j^i'oportion  of  the 
patients  who  were  vomited  early,  were  brought  to  the 
hospital,  and  there  underwent  the  disease  for  a  longer 
or  shorter  time ;  and  the  records  made  there  satisfied 
my  mind  as  to  the  disease.  At  last,  then,  comes  tho 
plain  question,  whether  I  was  able  to  distinguish  the 


ON  THE  TREATMENT  OF  TYPHOID  FEVER.   839 

disease.  To  this  I  shall  reply  plainly.  I  watched 
and  studied  this  fever  through  three  or  four  seasons 
when  it  Avas  epidemic,  and  the  sporadic  cases  of  it  for  • 
more  than  twenty  years  before  our  hospital  was 
erected ;  and  I  made  it  most  especially  my  study  to 
recognize  it  on  its  earliest  days.  I  believe  that  I 
studied  it  successfully ;  but  I  must  leave  it  to  those 
who  know  me,  to  decide  that  point. 

And,  now,  a  few  words  at  parting.  I  shall  take 
the  risk  of  repeating  what  I  have  said  before,  in  my 
desire  to  impress  on  you  what  I  think  essential  to 
your  well  doing. 

The  sick-room  is  to  be  the  field  of  your  labors.  To 
everything  which  occurs  there  you  are  to  give  your 
attention,  and  every  step  there  should  be  under  your 
direction.  Questions  of  the  deepest  importance  are 
constantly  arising  there  for  your  solution ;  questions 
on  the  constitution  of  man,  on  the  powers  and  the 
machinery  by  which  his  functions  are  performed,  on 
the  manifestation  of  disorder  in  those  functions,  and 
the  causes  which  may  induce  disorder,  on  the  mode  of 
restoring  health,  or  of  guarding  against  all  aggrava- 
tions of  disejtse,  so  as  to  allow  the  best  chance  for  a 
favorable  result  by  the  spontaneous  efforts  of  nature. 
These,  and  the  like  questions,  will  be  arising  constant- 
ly, and  you  must  be  prepared,  as  far  as  possible,  to 


840   ON  THE  TREATMENT  OF  TYPHOID  FEVER. 

meet  them.  Look  at  the  gardener  going  forth  to  his 
labors  furnished  with  all  the  tools  and  appliances 
which  can  aid  him  in  his  cunning  work,  —  thinking 
no  preparation  too  great,  no  precaution  too  small,  if 
he  can  thereby  make  success  more  certain.  See  him 
seeking  for  each  plant  the  site  mo&t  favorable  to  it, 
and  furnishing  it  with  the  soil  best  adapted  to  its 
wants.  Notice  how  minute  are  his  directions  to  his 
laborers,  trusting  as  little  as  possible  to  their  discre- 
tion. Do  not  cares  of  the  ■  like  sort,  looking  to  great 
and  small  things,  belong  to  the  physician,  who  has  to 
do  with  what  is  so  immeasurably  more  important  than 
the  fruits  and  flowers  of  the  garden  ?  He  must  be 
clear,  and  exact,  and  minute,  in  his  orders  to  the  nurse, 
as  the  gardener  is  to  his  laborers ;  remembering  that 
everything  may  depend  on  the  more  or  less,  on  the 
how  and  the  w^ien.  For  these  duties  the  physician 
cannot  be  prepared  without  the  utmost  familiarity  with 
the  sick-chamber.  This  is  to  the  physician  what  the 
garden  is  to  the  cultivator ;  the  place  for  which  all 
his  studies  and  labors  should  prepare  him,  and  where 
he  should  forever  be  advancing  more  and  more  toward 
a.  perfection  which  he  can  never  reach. 


INDEX 


Abscess  in  tonsils,  154. 

«         "      "       treatment,  155. 
Abscess  io  liver,  299. 
Agriculture,  compared  to  medicine,  12. 
Air,  in  intestines,  salutary,  243. 
"      "         "  injurious,  243. 

Alimentary  canal,  the  mutual  influence 

of  its  parts,  236. 
Animal  system,  its  organic  diseases,  46. 
Animal  Magnetism,  98. 

•'  "  common  doctrine  in 

respect  to  it,  99. 
"  "  another  doctrine,  99. 

Anxiety,  cause  of  dyspepsy,  213. 
Apoplexy,  74. 

Appetite,  a  pre-reqnisite  to  the  regula- 
tion of  diet,  217.  • 
Bile,  as  a  cause  of  disease,  132. 

"     false  notions  respecting,  132. 
Bilious  diseases,  297. 
Bladder,  irritable,  304. 
Bleeding,  in  pneumonitis,  165. 
"        "  hajmoptysis,  191. 
Boils,  306. 
"      their  varieties,  310. 
"      blind,  311. 
"      come  in  succession,  312. 
"      sometimes  epidemic,  312. 
"      their  causes,  313. 
"     treatment  of,  316. 
"     local  treatment,  323. 
Brain,  an  out-growth  of  the  organic  sys- 
tem, 44. 
Brandy,  223. 

29* 


Brandy,  caution  as  to  its  use,  224. 
Bronchitis,  158. 

«  treatment  of,  16^ 

Calculi,  biliary,  302. 
"       urinary,  303. 
"       mulberry,  303. 
Catarrh,  158,  160. 

"         treatment  of,  162. 
Cause  of  disease,  36. 
Cells,  division,  multiplication  and  ussa, 

45. 
Cholera  Infantum,  132. 

"  "  diagnosis,  134. 

"  "  treatment  of,  141. 

Chorea,  85. 

"      its  treatment,  85. 
"      fatal,  86. 

"      attending  second  dentition,  147. 
Clairvoyance,  102. 

"  tested,  103. 

Clergymen,  how  far  liable  to  hsemop- 

tysis,  201. 
Coffee,  222,  223. 
Cold,  a,  158. 
Colon,  enlargement  of,  243. 

"  "  "  treatment,  244. 

Combination  of  cathartics,  290. 
Condiments,  218. 
Constipation  of  bowels,  271. 

"  "      "      common  in  cities, 

271. 
"  "      "      causes  of,  271, 

"  "      "      treatment  of^ 

273. 


842 


INDEX. 


Constipation,  great  and  obstinate  occa- 
sionally, 292. 
**  treatment,  292. 

Convulsion  fits  of  children,  69, 110. 


"  "    "        "  treatment, 

70. 
Costiveness    attending  dyspepsy,  210, 
218. 
"  treatment  of,  219. 

Cure  of  the  sick,  16. 
"    "    "   priest,  16. 
"     "    "   physician,  16. 
Dejections  in  Cholera  Infantum,  to  be 
analyzed,  how,  136. 
"  as  to  their  frequency,  281. 

Dentition,  107. 

"        cause  of  disease,  107. 
"         second,  145. 
"  "        treatment  of,  147. 

Diarrhoea,  in  dentition,  110. 

"        in  teething  children,  129. 
"        before  the  period  of  dentition, 

130. 
"        attending  dyspepsy,  210. 
"        treatment  of,  239. 
Diet   and  regimen,  17 
"      in  infancy,  112. 
"      errors  of,  212. 
"        "        "  in  quantity,  212,  226. 
«        "        "   in  quahty,  212. 
"        "        "  in  frequency  of  meals, 

212. 
"    for  a  dyspeptic,  217,  221. 
"    for  constipation,  273. 
Directions  as  to  medicines,  &c.,  38. 
Double  consciousness,  case  of,  94. 
Dreaming,  92. 
Drink,  for  a  dyspeptic,  222. 
Drugs,  powerful,  caution  in  their  use, 
13. 
"      powerful,  abuse  of  them,  13. 
"      the  temper  with  which  they  are 
used,  14. 
Dysentery,  240. 
Dpspepsy,  203. 


Dyspepsy,  its  local  symptoms,  205. 
"  treatment  of,  211, 

"         medicinal  treatment  of,  229 
"         its  subsidence    in  old  age^ 
231. 
Education,  7. 

Enteritis,  in  teething  children,  112, 133. 
Epilepsy,  61, 

■*         paroxysm  of,  61. 
"  apoplectic,  63. 

"  its  termination,  64 

"         its  proximate  cause,  65. 
"         its  exciting  causes,  68. 
"         its  treatment,  67. 
Evidence,  examination  of,  27. 
Examination  of  cases,  method  of,  28. 
Exercise,  want  of,  cause  of  dyspepsy 
213. 
"        227. 

"        for  constipation,  279. 
Faint  turns,  in  epilepsy,  63- 
Feeding,  of  infants,  113. 
Fissure,  or  crevasse  in  rectum,  295. 
Flatulence  in  stomach,  207. 

"  "        "         how  far  decep 

tive,  207. 
Food,  liquid,  tepid  for  infants,  118. 
"      solid,  for  infants,  when,  118 
"      how  often,  118. 
"      animal,  119. 
"      withheld  in  night,  120. 
"     under  disease,  121. 
"      vomiting  and   regurgitation  of 

208. 
((  a  a  u  (( 

caused  by  some  tenderness  of  the 
stomach,  208, 
"      vomiting   of,  long-continued,    a 
case,  208. 
Furunculus,  306. 
Gall  stones,  302. 

Gastritis,  in  teething  children,  112, 133. 
Gout,  171. 

"      treatment  of,  171. 
Gruel,  mode  of  preparation,  115. 
IIseDFoptysis,  179. 


INDEX. 


343 


Haemoptysis,  from  a  tuberculous  cav- 
ity, 179. 
"  from     aneurism    in     the 

thorax, 180. 
"  case  of,    from  exhalation 

in  lungs,  181. 
"  diagnosis,  185. 

"  frequent     recurrence    of, 

189. 
"  treatment  of,  189. 

"  prognosis  in,  195. 

"  tiiree  cases  of,  196. 

Headaclie,  49. 

"  sick,  49. 

"  "      treatment  of,  51. 

"  intermittent  hemicrania,  54. 

treatment  of,  56. 

"  chronic,  57. 

"  "  treatment  of,  59. 

"  in  pregnancy,  59. 

"  attending  dyspepsy,  211. 

Heartburn,  its  causes,  207. 
Hemorrhoids,  295. 
Hippocrates,  18. 
Holyolie.  Dr.,  his  character,  19. 
Hosmer,  Dr.,  case  of,  192. 
Hydrocephalus,  72. 
Icterus,  299. 
Iliac  quarter,  247. 
Influenza,  161. 
Insanity,  104. 

"        treatment,  104. 
Intestines,  diseases  of,  232. 

"  physiology,  233. 

"  pathology  of,  235. 

"  causes  of  disease  in,  238. 

"  mode  of  studying  their  dis- 

eases, 242. 
Irritable  bladder,  304. 
Jaundice,  299. 
Liberal  profession,  9. 
Liver  diseases,  suspected,  244, 297. 
"        "  acute,  rare,  298. 

"        "  chronic,  not  very  rare, 

298.   • 


Living  beings,  the  simplest,  42. 

L 's,  Captain,  case.  194. 

Magnetism,  animal,  98. 
Medicine,  imperfect  as  an  art,  12,  23. 
"  "  "    "     "      not  so. 

comparatively,  12. 
"        practice  of,  not  limited  to  th« 
use  of  drugs,  15. 
Minot's,  Dr.,  cases,  257,  260. 
Mucous  membrane,  inflammation  of, 
111. 
"  "  eruptions  on.  111. 

Navigation,  compared  to  medicine,  11. 
Nervous  system,  42. 

"  "         an  outgrowth  of  the 

organic  system,  44. 

"  "  its   organic  diseases, 

46. 
"  "         its  normal  functions, 

47. 
"  "  its    simple    diseases, 

not  explicable,  48, 49 
Neuralgia,  87. 
Non-naturals,  112. 
Pain,  87. 
"      its  treatment,  89. 
"      or  uneasiness  in  breast,  attending 
dyspepsy,  211. 
Pamful  tumor  near  the  coecum,  248. 
Case  I.  of  the  above,  248. 
"    II.  of  the  above,  250. 
"    III.  of  the  above,  251. 
"    IV.  of  the  above,  252. 
"    V.  of  the  above,  254. 
"    VI.  of  the  above,  257. 
"   VII.  of  the  above,  260. 
Painful  tumor,  near  coecum,  symptoma 
of,  262. 
"         "        its  situation,  262. 
«         «        not  fiital,  262. 
"         "        its  pathology,  263. 
"  "        diagnosis,  264. 

"         •"        treatment  of,  268. 
Palpitation  of  the  heart  attending  dyg 

pepsy,  211. 
Palsy,  74. 


844 


INDEX. 


Palsy,  its  treatment  in  certain  cases,  76. 
"      cases  of,  77,  78. 
"      facial,  79. 

"  "      its  treatment,  79. 

"  "      cases  of,  80,  81. 

"      from  lead,  treatment,  82. 
"       mimotic,  82. 
"  "         its  treatment,  84. 

Peritonitis,  in  right  iliac  quarter,  247. 
Phlebitis,  with  suppuration,  266. 
Phthisis,  173. 

"         varying  with  age,  173. 
"         treatment  of,  174. 
"         long-continued,  after  haemop- 
tysis, two  cases,  197. 
Physician,  the  true,  his  pretensions,  15, 

16. 
Pneumonitis,  164. 

"  how  far  dangerous,  165. 

"  treatment  of,  165. 

Principles,  application  of   to  practice, 

10. 
Profession,  liberal,  9. 
Prolapsus  ani,  295. 
Quack,  16. 

"       remedies,  271. 
'*  "  objections  to  them, 

272. 
tjuinia,  its  mode  of  operation  in  certain 

cases,  320. 
Regurgitation  of  food,  208. 
Rheumatism,  167. 

«  acute,  167. 


Rheumatism,  treatment  of,  168. 
"  local,  169. 

"  in  small  joints,  169. 

Sick-room,  conduct  in,  25. 
Sleep,  perfect  or  imperfect,  92. 
Somnambulism,  93, 100. 
Spirit-rappers,  104. 
Symptoms,  objective,  30. 

"  subjective,  30. 

Tea,  222,  223. 
Teething,  107. 

Tumeurs   phlegmoneuses  des  fosses  ili- 
aqaes,  265. 
"        case  of  in  a  man,  266. 
"        case  of  in  a  woman,  266. 
Typhoid  fever,  treatment  of,  326. 

"  "      effect  of  emetics  on,  330, 

Ulcuscula  oris.  111,  150. 

"  "    hereditary,  150. 

"  "    acute,  152. 

"  "    treatment  of,  152. 

Uvula,  elongation  of,  156. 
"      amputation  of,  157. 
Vein,  suppuration  within,  266. 
Vertigo  attending  dyspepsy,  211. 
Vesication  in  haemoptysis,  191. 
Vomiting,  in  dentition,  109. 
Vomiting  of  food,  208. 
Weaning,  121. 

«         age  for,  123, 124. 
"         season  for,  124. 
Wine,  223, 
Worms  in  the  intestines,  148. 


^^ .  V^^^^tJi^^  , 


1 1  tym 


